DOG BITE / ATTACK INTAKE FORM Name * First Name Last Name Middle Name Phone # * (###) ### #### Email Address * Date of Birth MM DD YYYY Social Security Number (SSN) Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * Emergency Contact Relation * Emergency Contact Phone # * (###) ### #### Date of Incident * MM DD YYYY Time of Incident (approximate) * Hour Minute Second AM PM Location of the Incident. * Describe in your own words what occurred. * Were you on Private Property when attacked? * Yes No Unsure Were there "Beware of Dog" signs posted? * Yes No Not that I saw Responding Law Enforcement Agency & Report Number * Dog Owner Information * Provide the name, address, and contact details for the dog owner. Insurance Policy Provider and Policy Number of Dog Owner * What Breed of dog bit / attacked you? * Does the dog have past reported incidents or biting or other aggressive nature? * Yes No Unsure Did the dog's owner say anything to you? * Bodily Injuries * Area of body injured and description of your injuries. Were you transported via EMS to a Hospital? * Yes No Medical Treatment * List all medical providers you've been treated at since the incident including their name and address. Health Insurance Information * Referral * Thank you! We will be in touch soon to further discuss your case. Please note, that submitting an Intake Form does not create an attorney client relationship.
