Animal Bites Report Form

Health Care Provider Information

* Physician

Address

City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

Postal Code

* Phone xxx-xxx-xxxx

Fax xxx-xxx-xxxx

Person Bitten

* First Name

* Last Name

Address

Date of Birth Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900189918981897189618951894189318921891189018891888188718861885188418831882188118801879187818771876187518741873187218711870

City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

Postal Code

* Phone xxx-xxx-xxxx

Health Card Number

  Guardian information is the same as above

Exposure

Date of Exposure

Area on Body

Type of Animal Select Animal... Dog Cat Bat Other

Specify

Type of Exposure Select Type... Bite Scratch Handling Saliva Other

Explain

Animal's Habitat Select Habitat... Domestic Stray Wild

Description of Animal

Circumstances

Animal Owner Information

First Name

Last Name

Address

Postal Code

City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln Other

  Rabies Vaccine Recommended

PatientAccepts Declines

Circumstances

Specify

Phone xxx-xxx-xxxx

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.