Registration Form
MADDIE'S® SHELTER LAB
Introduction:

Maddie’s® Shelter* Lab provides registered 501(c)3 sheltering organizations with subsidized diagnostic testing for shelter and rescue-owned animals at a rate of 50% off testing fees and supplies using 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 at Cornell and the AHDC’s Veterinary Support Services.

Shelters and rescues in the following states are now eligible for Maddie’s® Shelter Lab’s subsidized diagnostic services: New York, Illinois, Indiana, Ohio, Pennsylvania, West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida, Maryland, Delaware, New Jersey, Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, and Maine.

To participate, each organization must register with the program and have

• 501c-3 status or equivalent non-profit status, and provide relevant proof;
• a 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 form that you must use when submitting samples for discounted samples. If you have any questions, please visit our website at www.sheltermedicine.vet.cornell.edu or email our Program Coordinator, Sarah Nickerson, at SN298@cornell.edu .


*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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