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KRISTINE GABOR Freeholder KEVIN L. THOMAS, M.A. Health Officer Public Health Coordinator JOSEPH R.TORDELLA, D.O. Medical Director CAPE MAY COUNTY DEPARTMENT of HEALTH 4 Moore Road Cape May Court House, N.J. 08210-1601 (609) 465-1210 after hours (609) 465-1190 Fax: (609) 465-6564 HD-EH-32 (REV. 02/10) New Jersey Revised Statute: 26:4-79 REPORT BY PHYSICIAN ATTENDING PERSON BITTEN BY ANIMAL: Every physician shall, within twelve (12) hours after his first professional attendance upon any person bitten by a dog, cat or other animal, report to the person designed by law the name, age, set and precise location of the person bitten. *****PLEASE PRINT***** INFORMATION ON PERSON BITTEN Office Use Only Account # Received Municipality Release Date of Bite Location Of Animal (by street and area at time of bite) Name of Person Bitten Age Sex Location Of Bite On Body Temporary Address Phone Permanent Address Phone Name And Address Of Guardian (if minor) Name of Reporting Physician Hospital Police INFORMATION ON ANIMAL/OWNER Type Of Animal: Dog Cat: Other: Breed Color Markings: Long or short hair Name of Owner and Permanent Address and Telephone Number Owners Temporary Address and Telephone Number Veterinarian Name and Address and Telephone Number 1 2 3 Name of Animal License Number Male or Female Date of Last Rabies shot Number of Years NOT WRITE BELOW THIS Investigation by this office revealed owner and responsible animal returned to Permanent address: Date Case Referred To: F F