LA County Department of Public Health - Online Reporting for Professionals


* Disease/Condition	* Animal Type	Add Other Animal Type Here	* # of Animals


Animal's Information

Animal #1 Condition Date Died Death Date Name
* Species Add Another Species Here Breed * Color Color Sex Age (eg – 8 weeks, 4 months, 2 years)



Reporter Information

* Last Name *First Name Clinic/Location Name
* Numeric Address * Street Name Street Type
* City Add New City Here *Zip
* Telephone Fax 555-555-5555 555-555-5555


Animal Owner's Information

Last Name First Name
Numeric Address Street Name Street Type
City Zip Telephone 555-555-5555


Animal Location Information (if different from owner's residence)

Last Name First Name
Numeric Address Street Name Street Type
City Zip Telephone 555-555-5555