Provider Animal Bite Report Form

Provider Animal Bite Report Form

Gallatin City-County Health Department
This notification form fulfills the Administrative Rules of Montana (ARM 37.114) requirements for disease reporting. All information transmitted through this form will remain private and protected in accordance with HIPAA.

* indicates a required field

Questions? Call us at 406-582-3100 Monday-Friday 8AM-5PM or 406-582-2100 ext. 2 after-hours
Patient Information
Patient name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code

Patient Information