Curbside Check-In Form – Animal Medical Center of Litchfield

Complete your form online!

Please fill this form out before your visit. If you need immediate assistance, please call our team directly at 217-324-3311.

I am in this vehicle: *

(please list model & color)

Best Phone number for today's appointment: *

Patient's Name *

Patient's Species *

Owner's Name *

First

Last

Appointment Date/Time *

Date

Time

Primary Reason for Appointment / Concern (please be as detailed as possible) *

Patient's Energy Level

List Medications your pet is currently taking

Do you need refills of any of these medications

Do you need refills on any prescription pet food?

Patient's Appetite

Drinking / Water Intake

Is the patient coughing?

Is the patient sneezing?

Is the patient vomiting?

Please upload any relevant photos / videos / records here

Click or drag files to this area to upload. You can upload up to 5 files.

Owner's Signature *

Clear Signature

Name