Peterson Law Offices: Dog Bite Intake Form

(503) 280-0888 [email protected]

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DOG BITE INTAKE FORM
(If you do not have some of the information we ask for, we will track it down for you.)
PERSONAL INFORMATION
Name(s)/ODL#
Phone Number
D.O.B
Date Format: 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 FACTS
Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Location (city/state/neighborhood) whre bit occurred
Briefly describe how the injury occurred
Was 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 INFORMATION
Name(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 INFORMATION
Name 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 INFORMATION
Employer
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

You must complete for form on the next page too, in order for Peterson Law Offices to legally represent you.

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825 NE 20th AVE - Suite 340 Portland , OR 97232-2275 - 503-280-0888
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PERSONAL INFORMATION

ACCIDENT FACTS

OWNER INFORMATION

OWNER INFORMATION

INJURIES:

MEDICAL TREATMENT PROVIDERS:

EMPLOYMENT AND INCOME INFORMATION

LIST ACHIEVEMENTS IN YOUR LIFE OR ACCOMPLISHMENTS