DOG BITE EVALUATION
A proper evaluation requires details.
Person Injured
*
Mr.
Mrs./Ms
Prefix
First Name
Middle Name
Last Name
Suffix
Are You Person Injured?
Yes
No
Full Name of Person Completing form
Prefix
First Name
Last Name
Suffix
Age of injured person
Child
Teenager
Adult
Senior Citizen
E-mail
Cell Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Your ZIP code
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Details about the Attack...
Do you Know Who the Dog Owner is?
Yes
No
Other
Where Did the Attack Occur?
Street Address
Street Address Line 2
City
State
Zip Code
Date & Time of Attack
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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Details about Animal...
Full Name of Dog Owner or Caretaker
First Name
Last Name
Do you know this person?
Person is NOT known to me
I only know person slightly
I don't want to sue this person
OK to file homeowner's claim
I will do what is necessary
Other
Breed of Dog
Don't know
Pit Bulls & Staffordshire Terriers
Doberman Pinschers
Rottweilers
German Shepherds
Chows
Great Danes
Presa Canarios
Akitas
Alaskan Malamutes
Siberian Huskies
Wolf-hybrids
None of the above
I don't know
What breed dog attacked you?
Dog's Behavior
Dog has been aggressive before
Dog has bitten someone before
Dog has threatened to bite another
Owner / Dog Walker did not control dog
Dog Escaped from House
Dog Escaped from Yard
Dog Broke free of Chain or Tether
Other
Have you Contacted Anyone else about this Event? Check ALL that applies.
Local Police
Animal Control
Owner or Person Harboring Dog
Doctor or other Health Care Provider
Another Attorney
Other Not listed above-explain below please
Other
Type of Residence of Dog Owner
House
Apartment
Other
Address of Dog Owner or Caretaker
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Injuries
It is critical to Know ALL injuries & treatment
Injuries
Fractures
Puncture Wounds
Infection
Dislocation
Lacerations
Contusions
Scar(s)
Amputation
Emotional Distress
Continuing Pain
Limits Movement
Bed Rest required
Numbness-Tingling
Nausea or Vomiting
Aggrevation of Pre Existing
Other
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Affects of Dog Bite Injuries
Fear
Sorrow
Anger
Anxiety
Saddness
Sleeplessness
Headaches
Dizziness
Difficulty Walking, Sitting, Standing
Nausea or Vomiting
Fatigue
Fainting
Depression
Vision Blurred, ringing in ears, sensory or memory problems
Other
Medical Treatment
Ambulance
Hospital or ER treatment
Personal Physician
Hospitalized
I received Medical Care IMMEDIATELY
Medical Care WITHIN 30 days of attack
I Have NOT received Medical care
I WANT to see an Injury Doctor
I am STILL under a Doctor's care
XRays
MRI
CT Scan
Prescription(s)
Pain Mgmt MD
Physical Therapy
Other
Activity Limitations as a Result of Dog Attack
Work / Job
Standing
Sitting
Walking
Running or Jogging
Housework
Gardening
Cooking
Religious Activities
Activities with my Children
Sports / Exercise
Pet Care
Travel
Other
Describe what Happened.
Add any details that stand out or not covered above.
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What is Value of My Claim?
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2do
No fault Insurance
3rd party Insurance
Health Insurance
subro insurance
Medical providers
Other
Done
No fault Insurance
3rd party Insurance
Health Insurance
subro insurance
Medical providers
Other
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