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 2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905190419031902190119001899189818971896189518941893189218911890188918881887188618851884188318821881188018791878187718761875187418731872

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

Postal Code

* Phone xxx-xxx-xxxx

Health Card Number Verified Yes
No

  Guardian information (name and contact information, if different from above)

Exposure

Date of Exposure

Area on Body

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

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

Rabies Vaccine Recommended Yes
No

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

Description of Animal

Circumstances

PatientAccepts
Declines

Animal Owner Information

If you don't know the animal owner's information, please type "unknown" in the fields below.

* First Name

* Last Name

* Address

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

Postal Code

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.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email foi@niagararegion.ca or call 905-980-6000 ext. 3779.