Your Name

First Name

Last Name

Practice/Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Additional Witness (if applicable)

First Name

Last Name

Client's Name *

First Name

Last Name

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's Primary Phone

(###)

###

####

Client's Secondary Phone

(###)

###

####

Client's Emergency Contact (if applicable)

First Name

Last Name

Client's Emergency Contact Phone Number (if applicable)

(###)

###

####

Client's Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the client the owner of the animal?

Yes

No

Unknown

Is the client and the suspect the same person? *

Yes

No

Is the suspect the owner of the animal?

Yes

No

Unknown

Suspect's Name (if not the owner)

First Name

Last Name

Suspect's Address (if not the owner)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Suspect's Phone Number (if not the owner)

(###)

###

####

Did the incident occur at the owner's address?

Yes

No

Unknown

Incident Date (most recent or most concerning vet appointment) *

MM

DD

YYYY

Incident Time (most recent or most concerning vet appointment) *

Hour

Minute

Second

AM PM

Reason for reporting (check all that apply)

Abandonment of animal

Dog fighting (i.e. numerous bite wounds in various stages of healing and/or overlapping scars localized to head, neck and/or front legs)

Emaciation or severely underweight without apparent medical reason

Hoarding (i.e. signs that the owner may have more animals than able to adequately care for)

Grooming, severely inadequate (i.e. extreme matting of fur, overgrown nails, dirty coat, indications of living in unsanitary conditions)

Parasite infestation, severe (i.e. flea, tick, myiasis)

Multiple injuries in various stages of healing

Suffering caused by ongoing, untreated injury or illness

Owner/Client reports causing harm (self-disclosure)

Owner reports third party causing harm

Animal shows signs of being struck or otherwise caused physical injury

Animal shows signs of sexual abuse

Unexplained injuries that do no match owner history

Has the client been notified that a report is being made?

Yes

No

Unknown

Are there safety concerns for the people in the home?

Yes

No

Unknown

Has the animal been seen by another veterinary clinic?

Yes

No

Unknown

Are there other animals in the home/on file?

Yes

No

Unknown

Are there children in the home?

Yes

No

Unknown

Do you have documentation, photos or video to submit? *

You will have the opportunity to make submissions on the next page.

Yes

No