Animal Bite Report Form

General Communicable Disease 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
Does patient work in any of the following sensitive occupations?*

Food HandlerPatient Care ProviderCongregate Living Care ProviderDay Care ProviderAttends DaycareNot Applicable

General Communicable Disease Report Form