DOG BITE INTAKE FORM(If you do not have some of the information we ask for, we will track it down for you.)PERSONAL INFORMATIONName(s)/ODL# Phone NumberD.O.B MM slash DD slash YYYY Marital Status SSN Name/adress/phone number of next to kin Have you had another lawyer work on this case? Yes No ACCIDENT FACTSDate MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Location (city/state/neighborhood) whre bit occurred Briefly describe how the injury occurredWas the dog fenced in, off leash, or otherwise? Yes No Was the Animal Control Bite Report Filed? Yes No Which Country? Bite Number Which police were on scene? State, City, and/ or County? Was the Police Report Filed? Yes No Were there any witnesses? Yes No The names and contact information of all witnesses OWNER INFORMATIONName(s) Address/phone number Does the dog owner own or rent his/her home? Name of property insurer, if known Police or Claim Number Adjuster/phone # OWNER INFORMATIONName of Dog Breed of Dog Does the dog have prior history of bites or aggressive behavior? Have any prior Animal Control reports been filed relating to the dog? What is the current status of the dog (i.e. was animal euthanized or given away)? INJURIES:What parts of your body were injured?Did you go to the doctor/hospital immediately after the accident? Yes No Name/phone # of doctor or hospital How did you get there? If by ambulance, what company? Do you have any photographs of your injuries shortly following the bite? Yes No Has a plastic surgeon evaluated your injuries? Yes No Name of doctor Phone number of doctor MEDICAL TREATMENT PROVIDERS:Doctor #1 Is treatment concluded? Yes No Doctor #2 Is treatment concluded? Yes No Doctor #3 Is treatment concluded? Yes No Do you have Medicaid, Medicare or private insurance? Do you have medical insurance? Yes No Name of Medical Insurance Co Medical Insurer Contact Info ID/Policy Number EMPLOYMENT AND INCOME INFORMATIONEmployer Employer Address Employer Phone #Job Title Job Description/Type of Work Pay Rate Hours worked/week Physical demands of your work; what job tasks have given you problems since the bite?Have you missed time from work because of your injuries? Yes No If so, how many days/hours have you missed? LIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS Δ You must complete for form on the next page too, in order for Peterson Law Offices to legally represent you.
