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Cayuga County Date of Animal Bite Form Time of Phone 253-1405 Fax 253-1478 Date of Parent’s Name Name: M / F DOB: if child: Person Bitten Address: Phone: Other Phone: Site of Skin Broken? Bite: Yes No Puncture Laceration Wound Date & Time of Treatment: Treatment: Treated Place of By: MD RN Treatment: Place of Occurrence: Incident Circumstances: Owner’s Name: Phone: Biting Owner’s Address: Town: Animal Animal Animal Type: Color: Sex: Age: Rabies Vaccination: Date: 1yr. 3yr. Tag # Agency and/or Person Calling in Report: Phone: Received by CCHD: Name: Date: Remarks: Health Dept. Animal Date Confined: Date: Place: Released: Only Person Ordering Confinement: Dept: Animal checked Animal’s By: Dates: Health: Animal checked Animal’s By: Dates: Health: Notes: