Animal Bites Report Form

Health Care Provider / Humane Society / Veterinarian

1. Provide contact information for the health care provider, humane society or veterinarian.

Name of person submitting this information *This question is required.

Are you a health care provider?

Address

Postal code

Work phone *This question is required.

Work email *This question is required. This question requires a valid email address.

Fax