Animal Bite Report

Animal Bite Report

Please fill out all fields with as much information as possible.

Date of Bite
Date

Month Day Year
Date

Form completed by:
NAME *

First Name Last Name
PHONE NUMBER *

Area Code Phone Number

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

Incident Information
ADDRESS WHERE BITE OCCURED *
CIRCUMSTANCES OF BITE *
DESCRIPTION AND EXTENT OF INJURY *

Medical Information
MEDICAL TREATMENT ADMINISTERED *
MEDICAL FACILITY
TREATING PHYSICIAN
PICTURE OF INJURY

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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

Is there anything else you would like to include in this report?
Should be Empty: