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 Date Format: MM slash DD slash YYYY Marital StatusSSNName/adress/phone number of next to kinHave you had another lawyer work on this case?YesNoACCIDENT FACTSDate Date Format: MM slash DD slash YYYY Time : HH MM AM PM Location (city/state/neighborhood) whre bit occurredBriefly describe how the injury occurredWas the dog fenced in, off leash, or otherwise?YesNoWas the Animal Control Bite Report Filed?YesNoWhich Country?Bite NumberWhich police were on scene? State, City, and/ or County?Was the Police Report Filed?YesNoWere there any witnesses?YesNoThe names and contact information of all witnessesOWNER INFORMATIONName(s)Address/phone numberDoes the dog owner own or rent his/her home?Name of property insurer, if knownPolice or Claim NumberAdjuster/phone #OWNER INFORMATIONName of DogBreed of DogDoes 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?YesNoName/phone # of doctor or hospitalHow did you get there?If by ambulance, what company?Do you have any photographs of your injuries shortly following the bite?YesNoHas a plastic surgeon evaluated your injuries?YesNoName of doctorPhone number of doctorMEDICAL TREATMENT PROVIDERS:Doctor #1Is treatment concluded?YesNoDoctor #2Is treatment concluded?YesNoDoctor #3Is treatment concluded?YesNoDo you have Medicaid, Medicare or private insurance?Do you have medical insurance?YesNoName of Medical Insurance CoMedical Insurer Contact InfoID/Policy NumberEMPLOYMENT AND INCOME INFORMATIONEmployerEmployer AddressEmployer Phone #Job TitleJob Description/Type of WorkPay RateHours worked/weekPhysical demands of your work; what job tasks have given you problems since the bite?Have you missed time from work because of your injuries?YesNoIf so, how many days/hours have you missed?LIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS You must complete for form on the next page too, in order for Peterson Law Offices to legally represent you.