PET PORTAL /
Online Pharmacy: THE FORMS YOU NEED IN ONE PLACE

FORMS

Use the following forms to fill out and submit directly through our site to UPSTATE AMC for our new/existing clients:
This helps us at UPSTATE AMC give you and your pet more time with Dr. Joy Lucas & Dr. David Tamas.

NEW CLIENT INFORMATION

Thank you for giving UPSTATE AMC the opportunity to care for your pet. Please help us to provide your pet with the best care by filling out the following form below & click the submit button:
(Any question with an * is required)

Owner(s)*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Cell Phone
How did you become aware of UPSTATE AMC?
Pet Name*
Species*
Breed*
Color
Birthdate
Date Format: MM slash DD slash YYYY
Sex (Altered)?
- Male
- Female
- Neutered
- Spayed
- Not Sure
Last seen by a vet?
Date Format: MM slash DD slash YYYY
Previous Vet
Second Pet Name
Species
Breed
Color
Birthdate
Date Format: MM slash DD slash YYYY
Sex (Altered?)
Last seen by a vet?
Previous records from your pet's last vet? Please have them emailed to info@upstateamc.com or faxed to us at 518.583.1014
- Yes
- No
- Unavailable
Do you have an appointment with us? * Please Note, if not we will not contact you but your email will be saved for a future appointment.*
- Yes
- No
Have any more pets? Fill out this section with their info.
Comments
PAYMENT Written estimates will be supplied on request gladly. All fees are due at the time of services rendered.*
- I agree
Date
Date Format: MM slash DD slash YYYY

NEW CLIENT INFORMATION FORM

FILE UPLOAD

If you need to send us files this is the place to do it. Please fill out the following form below, attach the necessary files & click the submit button:
(Any question with an * is required)

Name:*
Pets Name:*
Email*
Subject:*
Upload File*
File must be 10 MB or less

FILE UPLOAD

DOG/CAT HISTORY FORM

Have a dog or cat that is new to us?
Please fill out the following form below as well as you can & click the submit button. Do not worry if you cannot answer everything. Having even some of the information will allow you to get more out of your time with Dr. Lucas or Dr. Cherry:
(Any question with an * is required)

Name:*
Email*
Pet Name*
Species*
- Canine
- Feline
Breed/Mix*
Date of Birth*
Date Format: MM slash DD slash YYYY
How long have you had your pet?*
Sex*
- Female
- Male
- Female Spayed
- Male Neutered
Do you have previous vet records? * Please forward them to our office if you haven't already done so*
- Yes
- No
Have there been any changes in the pet's enviroment?
Have you noticed any of the following? *Check all that apply*
- Weight Loss
- Weight Gain
- Increased Appetite
- Decreased Appetite
- Vomiting
- Increased Urination
- Decreased Urination
- Difficulty Urinating
- Diarrhea
- Constipation
- Excessive Shedding
- Hair Loss
- Scratching
- Skin sores, lumps
- Difficulty Breathing
- Coughing
- Sneezing
- Ear Issues
- Nasal Discharge
- Eye Discharge
- Decreased Activity
- Anxiety
- Lethargy
- Head Tilt/Balance Issues
- Limping
- Pain
- NONE OF THE ABOVE
If you have noticed any of the problems in the check list, please describe in detail.
Vaccine History? Enter current dates if known.
Do you have an appointment with us?*
- Yes
- No
- Not Yet
If so, when
Date Format: MM slash DD slash YYYY
: HH

MM

DOG/CAT HISTORY FORM

AVIAN HISTORY FORM

Have a bird that is new to us?
Please fill out the following form below as well as you can & click the submit button. Do not worry if you cannot answer everything. Having even some of the information will allow you to get more out of your time with the Dr.Lucas:
(Any question with an * is required)

Owner(s)*
Email*
Pet Name*
Species*
Date of Birth*
Date Format: MM slash DD slash YYYY
How long have you had your bird?*
Choose all that apply*
- Bird is a Pet
- I am a Breeder
- Has produced young/eggs
Comments to any above
How did you acquire your bird?*
- Store
- Private Party
- Breeder
- Other
Sex*
- Female
- Male
- Unknown
Do you have previous vet records? * Please forward them to our office if you haven't already done so*
- Yes
- No
How often is your bird handled?*
- Everyday
- Occasionally
- Never
Does your bird go outside?*
- Often
- Sometimes
- Never
Check all that apply. Bird kept in:*
- Cage
- Aviary
- Free in the house
- Wings trimmed
Other birds kept in same cage or aviary?*
- No
- Yes
Please list other birds on the premises, indoors or outdoors*
Briefly describe the cage; average size, perches, where it is located house, full spectrum (UVB) bulb, bedding, how often cleaned...*
What kind of food do you feed your bird?*
- Pellets
- Seed
- Fruits
- Vegetables
- Table Food
Briefly describe the brand and types of foods along with percentage of diet.*
Are any of those birds sick? Have any died? If yes, give details*
List other pets in the home or yard:*
Have you noticed any of the following? *Check all that apply*
- Diarrhea
- Constipation
- Change in Stool Consistency
- Change in Weight
- Change in Appetite
- Excessive Water Consumption
- Vomiting/Regurgitation
- Difficulty Breathing
- Tail Bobbing
- Difficulty Perching
- Issues with Sight
- Drooping or Injured Wings/Legs
- Lethargy
- Fluffed Feathers
- Stool Caked to vent
- Feather Picking
- Nasal/Eye Discharge
- NON OF THE ABOVE
If you have noticed any of the problems in the check list, please describe in detail.
Check all (if any) that your bird has been tested for.
- Chlamydophila (Psitticosis)
- Polyomavirus
- Psittacine Beak and Feather
- Avian Bornavirus
- Parasites
- Other
If answered other to above please describe in detail.
Vaccine History? Enter any vaccines your bird as been given and the date.
Seen by another vet? When/Why?
Has the bird been dewormed?
- Yes
- No
Treatment used for deworming?
Additional comments
Do you have an appointment with us?*
- Yes
- No
- Not Yet
If so when:
Date Format: MM slash DD slash YYYY
: HH

MM

AVIAN HISTORY FORM

SMALL EXOTIC MAMMAL HISTORY FORM

Have a small exotic mammal that is new to us? Please fill out the following form below as well as you can & click the submit button. Do not worry if you cannot answer everything. Having even some of the information will allow you to get more out of your time with Dr. Lucas: (Any question with an * is required)

Owner(s)*
Email*
Pet Name*
Species*
Date of Birth*
Date Format: MM slash DD slash YYYY
How long have you had your pet?*
Sex*
- Female
- Male
- Unknown
Do you have previous vet records? * Please forward them to Upstate AMC. Fax to 583.1014*
- Yes
- No
Where did you obtain your pet?*
Type of enclosure/cage?*
What are the enclosure dimensions?
Where is the enclosure located?
How of often is the enclosure cleaned?
Does Your pet spend time out of the cage?
- Yes
- No
If answering yes. How much time and where?
Do other animals share the cage?*
- No
- 1
- 2 or More
How often is your pet handled?
What kinds of food and treats do you give your pet?
Please list any previous medical problems.
Has your pet recently exposed to other animals? Boarding, New Addition?*
- Yes
- No
Has ther been any change in the pet's enviroment?
Have you noticed any of the following? *Check all that apply*
- Weight Loss
- Weight Gain
- Increased Appetite
- Decreased Appetite
- Vomiting
- Increased Urination
- Decreased Urination
- Difficulty Urinating
- Diarrhea
- Constipation
- Unusual muscle tremors
- Problems Shedding
- Scratching
- Skin sores, masses, lumps
- Wounds
- Difficulty Breathing
- Coughing
- Sneezing
- Ear Issues
- Nasal Discharge
- Eye Discharge
- Eyes closed or partially closed more than usual
- Decreased Activity
- Anxiety
- Restless
- Lethargy
- Loss of Balance
- More time hiding
- Spending more time in cooler areas than usual
- Spending more time in the basking area than usual
- Prolonged soakings in the water bowl Limping
- Pain
- NONE OF THE ABOVE
If you have noticed any of the problems in the check list, please describe in detail.
Additional comments
Do you have an appointment with us?*
- Yes
- No
- Not Yet
If so when:
Date Format: MM slash DD slash YYYY
: HH

MM

SMALL EXOTIC MAMMAL HISTORY FORM

SMALL EXOTIC REPTILE HISTORY FORM

Have a small exotic reptile that is new to us?
Please fill out the following form below as well as you can & click the submit button. Do not worry if you cannot answer everything. Having even some of the information will allow you to get more out of your time with Dr. Lucas:
(Any question with an * is required)

Owner(s)*
Email*
Pet Name*
Species*
Date of Birth*
Date Format: MM slash DD slash YYYY
How long have you had your pet?*
Sex*
- Female
- Male
- Unknown
Do you have previous vet records? * Please forward them to Upstate AMC. Fax to 583.1014*
- Yes
- No
Where did you obtain your pet?*
Type of enclosure/cage?*
What are the enclosure dimensions?
Where is the enclosure located?
How of often is the enclosure cleaned?
Does Your pet spend time out of the cage?
- Yes
- No
If answering yes. How much time and where?
Do other animals share the cage?*
- No
- 1
- 2 or More
How often is your pet handled?
What kinds of food and treats do you give your pet?
Please list any previous medical problems.
Has your pet recently exposed to other animals? Boarding, New Addition?*
- Yes
- No
Has ther been any change in the pet's enviroment?
Have you noticed any of the following? *Check all that apply*
- Weight Loss
- Weight Gain
- Increased Appetite
- Decreased Appetite
- Vomiting
- Increased Urination
- Decreased Urination
- Difficulty Urinating
- Diarrhea
- Constipation
- Unusual muscle tremors
- Problems Shedding
- Scratching
- Skin sores, masses, lumps
- Wounds
- Difficulty Breathing
- Coughing
- Sneezing
- Ear Issues
- Nasal Discharge
- Eye Discharge
- Eyes closed or partially closed more than usual
- Decreased Activity
- Anxiety
- Restless
- Lethargy
- Loss of Balance
- More time hiding
- Spending more time in cooler areas than usual
- Spending more time in the basking area than usual
- Prolonged soakings in the water bowl Limping
- Pain
- NONE OF THE ABOVE
If you have noticed any of the problems in the check list, please describe in detail.
Additional comments
Do you have an appointment with us?*
- Yes
- No
- Not Yet
If so when:
Date Format: MM slash DD slash YYYY
: HH

MM

SMALL EXOTIC REPTILE HISTORY FORM

Online Rx / Food / Preventatives

Use the link below to request meds, food, preventatives conveniently & affordably delivered to your door:

PET PORTAL /Online Pharmacy: THE FORMS YOU NEED IN ONE PLACE

FORMS

NEW CLIENT INFORMATION

FILE UPLOAD

DOG/CAT HISTORY FORM

AVIAN HISTORY FORM

SMALL EXOTIC MAMMAL HISTORY FORM

SMALL EXOTIC REPTILE HISTORY FORM

Online Rx / Food / Preventatives

PET PORTAL /
Online Pharmacy: THE FORMS YOU NEED IN ONE PLACE