1. What disease is being reported? Please also provide the name or ID, age, sex, breed, and/or species of the animal(s) involved.
(Required)
2. Veterinarian's name and preferred contact information
(Required)
3. Owner/Caretaker name, address, phone number, and/or email
4. Physical address of the animal(s)
5. When was the animal obtained? If recently obtained, what was the source? (provide contact information for rescue, breeder, farm, market, etc.)
6. Please provide history and case information, and any additional information or comments below