Animal Care Services
Animal Bite Report Form
Date: December 19, 2014
Fields marked with an asterisk (*) indicate a required field.
  Person Reporting Information
* First Name:
* Last Name:
* Phone: 111-111-1111
Email
Are you the victim?
Relationship to Victim:
  Victim's Information
* Victim's First Name:
* Last Name:
* Victim's DOB: MM/DD/YYYY
Age:
* Victim's Address:
* City:
* State:
* Zip:
* Phone: 111-111-1111
Location of Wound:
  Bite Information
* Date of Bite: Pick a date
Time of Bite: HH:MM   AM PM
Where Bite Occurred: (Sidewalk, Friend's House, etc...)
Nearest Address or Cross Street Where Bite Occurred:
City:
State:
Zip:
Describe How the Bite Occurred:
  Victim's Treatment Information
Treatment Description:
Date of Treatment: Pick a date
Treated by: (if known)
Physician or Facility Name:
Phone: 111-111-1111
  Animal Information
* Animal Type: (dog ,cat ,etc...)
Breed: (pitbull, shepard, etc...)
Sex:
Animal's Name:
  Animal Owner's Information (if known)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone: 111-111-1111
Additional Comments