Report An Animal Bite Form

Type of bite

laceration

mauling

multiple

puncture

scratch

severe

Date of bite

Month

-

Day

-

Year

Owner's name

Owner's address

Street Address
Street Address 2
City	State
Zip Code	Country

Owner's date of birth

Month

-

Day

-

Year

Type of animal

Animal's Name

Animal's date of birth or approximate age

Breed of animal

Has this animal ever bitten before?

Yes

No

Unknown

Was the animal confined at the time of the bite?

Yes

No

On-leash

Victim's first and last name

First Name
Last Name

Victim's address

Street Address
Street Address 2
City	State
Zip Code	Country

Victim's email (if over the age of 18)

Guardian's phone number (if victim is under the age of 18)

Area CodePhone Number

Guardian's date of birth (if victim is under the age of 18)

Month

-

Day

-

Year

Did the victim seek treatment?

Home

Physician

None

Circumstances leading up to the bite.

Report an Animal Bite