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Veterinary Public Health

   
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 Wound:
 
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
Treatment Description:
Treated by: (if known)
Physician or Facility Name:

Date of Treatment:
Phone: 555-555-5555
 
Animal Information
* Animal Type: (dog ,cat ,etc...) Breed: (pitbull, shepard, 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
*Code:   What's this? | Refresh for a new code(Refresh)
 

  

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