Animal Bite Report
Please fill out all fields with as much information as possible.
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Date of Bite
Date
*
-
Month
-
Day
Year
Date
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Form completed by:
NAME
*
First Name
Last Name
PHONE NUMBER
*
-
Area Code
Phone Number
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Victim Information
NAME
*
First Name
Last Name
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER
*
-
Area Code
Phone Number
EMAIL
example@example.com
DOB
*
/
Month
/
Day
Year
Date
AGE
*
GENDER
*
PARENT/GUARDIAN NAME (if victim is a minor)
First Name
Last Name
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Incident Information
ADDRESS WHERE BITE OCCURED
*
CIRCUMSTANCES OF BITE
*
DESCRIPTION AND EXTENT OF INJURY
*
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Medical Information
MEDICAL TREATMENT ADMINISTERED
*
MEDICAL FACILITY
TREATING PHYSICIAN
PICTURE OF INJURY
Browse Files
Cancel
of
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Owner of Animal
OWNER OF ANIMAL
First Name
Last Name
OWNER'S ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
OWNER'S PHONE NUMBER
-
Area Code
Phone Number
Description of Animal
Name
Species/Breed
Color
Sex
Age
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Is there anything else you would like to include in this report?
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