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Veterinary Public Health
LA city


Person Reporting Information
* First Name: * Last Name:
* Phone: 555-555-5555 Email:
* Reporting Agency:
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
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 Occured:
* City:      State:      Zip:

Describe How the Bite Occurred:

Victim's Treatment Information
Location of Wound:
Treatment Description:
Was victim Hospitalized? YesNo
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:   Color: Animal's Name:
* Animal Impounded? Yes No Impound No.:
Taken to clinic for treatment? Yes No Clinic Name:
Clinic Address: Clinic Phone:
Current Rabies Vaccination? Yes No Date Vaccinated:
Animal Sterilized? Yes No Animal Died? Yes No
Animal Licensed? Yes No License Number:
License Expiration Date: City/County License in:
Euthanized? Yes No Date Euthanized:
Specimen ready for pickup? Yes No Shelter:
Animal Owner's Information (if known)
First Name: Last Name:
City:      State:      Zip:
Phone: 555-555-5555
Please provide us with any additional comments
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