Farm & Family Veterinary Service

Farm and Family Vet

farmandfamilyvet.com

Call: 217-826-3185 | Directions | Emergencies

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Curbside Care Appointment Intake Form

Sick Pet Appointment Form

Please use this form for sick patient appointments only.  If your pet is visiting for wellness (vaccines, preventatives), please use this form instead.

Please fill out this form as completely and accurately as possible prior to your appointment. If you have questions or are experiencing an emergency, call us directly at 217-826-3185.

"*" indicates required fields

Owner's Name*
MM slash DD slash YYYY
(Please be as detailed as possible)
Patient's Energy Level
Which of the following preventatives are used? (check all that apply)
(N/A if not on any medications)
Please check any symptoms that your pet is experiencing:
Drop files here or
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 128 MB.
    You may attach previous records from another vet clinic or shelter here if needed. Please use pdf or jpg if possible. Alternately, you can email them to farmandfamilyvet@gmail.com with your pet's first and last name as the subject.
    Medium Crossroads6