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

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

*Code:	What's this? \| (Refresh)