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Animal Bite Report Form (* Required Fields)

Person Reporting Information
*First Name:	* Last Name:
* Phone: 555-555-5555	Are you the victim? Yes No Relationship to Victim:
Email:

Victim's Information
* First Name:	* Last Name:
* Victim's DOB: mm/dd/yyyy	Age:
* Victim's Address:
* City: Add New City Here:
* State: * Zip: * Phone: 555-555-5555
Location of Bite (check all that apply): Face (head, neck, lip, etc.) Arm (shoulder, elbow, etc.) Hand (wrist, palm, fingers, etc.) Torso (stomach, back, etc.) Pelvic region (buttocks, hips, etc.) Leg (knee, thigh, etc.) Foot (ankle, heel, toes, etc.) Unknown Other: Which side of the body is bite located? Left Right Both Unknown

Bite Information
* Date of Bite:	Time of Bite: : HH:MM AM PM
Where Bite Occurred: (Sidewalk, Friend's House, etc...)
Nearest Address or Cross Street Where Bite Occurred:
City: State: Zip:
Describe How the Bite Occurred:

Victim's Treatment Information
Type of treatment (check all that apply): Antibiotics Wound care Tetanus (Tdap) vaccine Pain management Sutures Surgery Rabies PEP Other:
Treated by: (if known) Physician or Facility Name:	Date of Treatment:
Phone: 555-555-5555

Animal Information
* Animal Type: (dog ,cat ,etc...)	Breed: (pitbull, shepherd, etc...)
Sex:	Animal's Name:

Animal Owner's Information (if known)
First Name:	Last Name:
Address:
City: State: Zip:
Phone: 555-555-5555

Please provide us with any additional comments