Pet Parasite Exposure Report Form
Report suspected or confirmed parasite exposure in pets. Please complete all relevant details for accurate assessment.
Reporter Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Pet Name
*
Pet Species
*
Please Select
Dog
Cat
Bird
Rabbit
Reptile
Other
Pet Age
*
Type of Parasite or Exposure
*
Fleas
Ticks
Worms (e.g., roundworm, tapeworm)
Mites
Other
Date and Time of Suspected Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Symptoms Observed
*
Itching or scratching
Hair loss
Diarrhea or vomiting
Lethargy
Visible parasites
Other
Suspected Source of Exposure
*
Please Select
Outdoor environment
Contact with other animals
Contaminated food/water
Shelter/boarding facility
Unknown
Other
Are other animals affected?
*
Yes
No
Unknown
Additional Notes or Evidence (optional)
Submit Report
Should be Empty: