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Registration Form
MADDIE'S® SHELTER LAB
Introduction:
Maddie’s® Shelter Medicine Program at Cornell and Maddie’s Fund® are excited to announce the new Maddie’s® Shelter Lab in collaboration with the New York State Animal Health Diagnostic Service (AHDC).

This program will provide registered 501c-3 organizations with subsidized diagnostic testing for shelter and rescue animals at a rate of 50% off testing fees and supplies and free shipping labels via UPS Ground. Additionally, phone and email consultation services are available to provide counseling on test submission, result interpretation, and outbreak management through veterinarians in Maddie’s® Shelter Medicine Program and the AHDC’s Veterinary Support Services.

At this time, only New York State shelters and rescues are eligible. In order to participate, the organization must register with the program and have

• 501c-3 status or equivalent non-profit status, and provide relevant proof;
• a NYS licensed vet of record to whom results will be transmitted.

Once your registration is verified and approved, you will be contacted with an account number and pre-populated submission forms that you must use when submitting samples for discounted samples.

*Made possible by a grant from Maddie’s Fund.

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ORGANIZATION INFORMATION
All organizations must be in New York State and be able to provide a tax-exempt ID number.
Name of registering organization:
Tax-exempt ID number:
Organization email address:
Organization phone number:
ORGANIZATION'S MAILING ADDRESS
Street address:
City
State:
Zip code:
ADDITIONAL INFORMATION
How would you characterize your organization (select all that apply)?
Required
If you answered "Other" to the previous question, please explain here:
How many animals does your organization see every year?
What types of species do you treat?
Required
Which services does your organization provide?
Required
CONTACT PERSON'S INFORMATION
The person filling out this form should fill in their contact info below.
Contact person's name:
Contact person's title:
Contact person's phone number:
Contact person's email address:
LICENSED VETERINARIAN INFORMATION
Please provide the contact information of the licensed veterinarian to whom the diagnostic results will be released to.
Full name:
Phone number:
Email address:
Veterinarian license number:
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