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Veterinary Diagnostics
New Client Form
* = required field
Clinic name*
Mailing address*
(statements will be mailed to this address the first of each month for the previous month’s services.)
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Address for sample pickup
(if different)
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Phone*
After hours phone
(so we can return calls at lunch, after closing, etc.)
Fax
(reports will be sent by fax to this number)
Email*
Preference for results:
fax
email
both
Doctors’ names
(first and last names please)
Head Tech’s name
(or other contact person)
Clinic hours
How did you hear about VDx?
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