Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pet's Name *

First Name

Last Name

Birthday (estimated) *

MM

DD

YYYY

Bite History: Human Directed *

This is for information purposes and will not be reported

Level 0: No Aggression Shown.

Level 1: Harassment, Hissing, Growling, Barking, Air biting, Lunging, or Snapping. Bite did not make contact or touch the skin.

Level 3: 1-4 punctures from a single bite or scratch, no tearing (all punctures < ½ length of the canine tooth /fang or claw).

Level 4: 1-4 punctures from a single bite or scratch, tearing, headshake (all punctures > ½ depth of the canine tooth/fang or claw).

Level 5: Multiple level 3 or level 4 bites or scratches from a single aggressive incident.

Level 6: Bite/scratch resulted in fatality/death.

* Incident(s) reported to Animal Control or Police

* Medical care required or opted

Behavior Concerns *

Check all that apply

Separation anxiety

Fear

Aggression

Introduction / Integration

Enrichment

Other