LA County Department of Public Health - Animal Bite

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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 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

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