A Test

Please tell us about you
Your Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*

When was the incident? If you don't know the exact date, please give an estimate of when/how long ago.	Please describe the person/people bitten. Please include age, gender, actions, e.g. 10-year-old boy waving stick.	Actions

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