Animal Bite Affidavit
PUBLIC ANIMAL WELFARE SERVICES
Patient First Name
*
Patient Last Name
*
Patient Address
*
Patient City
*
Patient State
*
GA
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Patient Zip Code
*
Patient Phone Number
*
Patient Email Address
Date of Birth
*
Is Patient Under Age 18?
*
No
Yes
Guardian's Name
*
Driver's License No.
*
Select Choose File and Take Picture of your Driver’s License
*
Date of Bite
*
Time of Bite
Address Where Bitten
*
Circumstances of the bite?
*
Detailed Description of Animal
*
Nature and location of injury
*
Treatment Given
Treatment received at:
Floyd Medical Center or Clinic
Redmond Hospital or Clinic
Harbin Clinic
Other Medical
Self or Non-medical person
Owner's name (if Known)
Owner's Phone Number(if known)
I swear (or affirm) that the information in the statement above is true and best of my knowledge or belief.
Signature
*
Clear