Republic of the Philippines

CITY OF CALOOCAN
Caloocan City North Medical Center
BARANGAY 177 CAMARIN ROAD CALOOCAN CITY

ANIMAL BITE TREATMENT CENTER

REFERRAL FORM Date:
Name: Age: Sex:
Address:
Referred from:
Referred to:
Site of Bite:
Date of Bite:
Nature of Bite:
Place of Bite:

(+) (-) Previous History of Animal Bite

(+) (-) Previous History with Anti Rabies Injection
Condition of Dog/Cat: [ ] Health/Alive [ ]Sticky
[ ] Lost/Cannot be observed/Stray [ ] Died
Name of Owner (Animal):
Owner’s Address:
Treatment Given at CCNMC-ABTC:

Diagnosis:
Purpose of Referral:

Please come back at Caloocan City North Medical Center

(Animal Bite Treatment Center) on
Date

Referred By: