Dog Bite / Attack Client Name * First Name Last Name Client Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Client Email * Client Phone # * (###) ### #### Date of Birth * MM DD YYYY Social Security Number * Secondary Contact Person's Name * First Name Last Name Secondary Contact Person's Relation to You * Secondary Contact Person's Phone # * (###) ### #### Date of Incident * MM DD YYYY Describe the Incident * Were you on Public or Private Property? * Public Property Private Property Unsure Were there any "Beware of Dog" signs? * Yes No Unsure Dog Owner's Name First Name Last Name Dog Owner's Phone # (###) ### #### Dog Owner's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Dog Owner's Insurance Information * Previous Incidents Involving Dog * Dog Breed or description * Communications with Dog Owners * Injuries Sustained * Medical Treatment * List all medical providers you have seen since this incident. Provide the facility name, address, and dates of service. Law Enforcement or Animal Control Response? * Yes No Unsure Were you transported via EMS / Ambulance to a hospital or ER * Yes No Hospital or Urgent Care Treatment. * Name the facility, address, and dates of service at any hospital, ER, or Urgent Care. Other Attorneys Consulted? * How did you hear of us? Social Media (Fabebook, Instagram, Twitter) Google Family or Friend Referral Thank you!
