Practice Information Update Form

In order to help us communicate more efficiently with your practice, please provide below any changes to the contact information for your practice, as well as any veterinarian staffing changes, as they occur. This form can be faxed to us at 217-244-9554 or emailed to medrec@vetmed.illinois.edu. Thank you for being part of our team.

Practice update Form

Address(Required)
If you do not have an email for the office type N/A@nothing.com
Preferred method of communication(Required)
Please list the full name and email address of the veterinarian(s).
Please list the full name and email of veterinarian(s) no longer representing your practice.
Please type your name and date below as authorization to make these changes.
Consent(Required)