Form 4110 - Wslh Rabies Requisition Form Page 2
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1
2Additional Human Exposure Information
nd
2A. 2
Person Exposed
Exposure Date ____/____/____
Physician (**required**)
Name ___________________________________________
Address _________________________________________
Name _____________________________________________
City/State/Zip ____________________________________
Clinic Name ________________________________________
Date of Birth ________________ Age ________ Sex ____
City/State/Zip _______________________________________
Phone #: 1st (______)_________ 2nd (______)__________
Physician Phone (_____)______________
Type of Exposure:
Post Exposure Treatment:
Anatomical Site
□ Bite
□ Scratch
Vaccine □ Yes □ No
Date initiated ____________
□ Lick
□ Unknown
□ Yes □ No
HRIG
Date initiated ____________
□ Other __________________
□
None
rd
2A. 3
Person Exposed
Exposure Date ____/____/____
Physician (**required**)
Name ___________________________________________
Address _________________________________________
Name _____________________________________________
City/State/Zip ____________________________________
Clinic Name ________________________________________
Date of Birth ________________ Age ________ Sex ____
City/State/Zip _______________________________________
Phone #: 1st (______)_________ 2nd (______)__________
Physician Phone (_____)______________
Type of Exposure:
Post Exposure Treatment:
Anatomical Site
□ Bite
□ Scratch
Vaccine □ Yes □ No
Date initiated ____________
□ Lick
□ Unknown
□ Yes □ No
HRIG
Date initiated ____________
□ Other __________________
□
None
Additional Animal Exposure Information
nd
2B. 2
Animal Exposed
Exposure Date ____/____/____
Species
Age
□ Yes □ No □ Unkn
_______________________
Rabies Vaccination Current?
Owner (of exposed animal)
Type of Exposure:
Anatomical Site
□
□ Scratch
____________________________________
Bite
Address
□
□ Unknown
Ingestion
□
□ Other __________
________________________________
Lick
City/State/Zip
rd
2B. 3
Animal Exposed
Exposure Date ____/____/____
Species
Age
□ Yes □ No □ Unkn
_______________________
Rabies Vaccination Current?
Owner (of exposed animal)
Type of Exposure:
Anatomical Site
□
□ Scratch
____________________________________
Bite
Address
□
□ Unknown
Ingestion
□
□ Other __________
________________________________
Lick
City/State/Zip
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