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ANIMAL DISEASE LIST
	Reportable Disease List * must provide value	Arboviral encephalitides Carbapenem-resistant organism Leptospirosis Other Psittacosis Rocky Mountain spotted fever Salmonellosis SARS-CoV-2 Tuberculosis reset
	If other, please specify
VETERINARY OR PROVIDER INFORMATION
	Animal hospital or facility name (If your facility is not listed, choose "Other" and provide the address.)	Other145TH STREET ANIMAL HOSPITAL4 LEGGED FRIENDS VETERINARY CLINICAAA VETERINARY CLINIC - ASTORIAAAA VETERINARY CLINIC - JACKSON HEIGHTSAADOBE ANIMAL HOSPITALABC ANIMAL HOSPITALABINGDON SQUARE VETERINARY CLINICALL PETS VETERINARY CAREANIMAL CARE AND CONTROL - BRONXANIMAL CARE AND CONTROL - BROOKLYNANIMAL CARE AND CONTROL - MANHATTANANIMAL CARE AND CONTROL - QUEENSACC_STATEN ISLAND, ANIMAL CARE AND CONTROL - STATEN ISLANDANIMAL CLINIC & SURGERY OF THROGGS NECKANIMAL CLINIC OF 20TH AVENUEANIMAL CLINIC OF BAY RIDGEANIMAL CLINIC OF CANARSIEANIMAL CLINIC OF HOLLIS COURTANIMAL CLINIC OF LONG ISLAND CITYANIMAL CLINIC OF MARINE PARKANIMAL CLINIC OF NEW YORKAC_QUEENS - FLUSHING, ANIMAL CLINIC OF QUEENS - FLUSHINGANIMAL CLINIC OF QUEENS - MIDDLE VILLAGEANIMAL CLINIC OF WOODHAVENANIMAL ENDOCRINE CLINICANIMAL GENERAL HOSPITALANIMAL HEALING ARTS OF CARROLL GARDENS AT HOMEANIMAL HEALTH CENTERANIMAL HEALTH GROUP ON CASTLETONANIMAL HOSPITAL OF BROOKLYNANIMAL HOSPITAL OF CHELSEAANIMAL HOSPITAL OF MORRIS PARKANIMAL HOSPITAL OF STATEN ISLANDANIMAL HOSPITAL OF THE ROCKAWAYSANIMAL KIND VETERINARY HOSPITALANIMAL MEDICAL CENTERANIMAL MED & SURGERY CLINICANIMAL MEDICINE & SURGERY OF LITTLE NECKANNADALE VETERINARY CLINICANTELYES ANIMAL HOSPITALAQL DOG AND CAT CLINICARMORY DOG & CAT HOSPITALASPCA- BERGH MEMORIAL ANIMAL HOSPITALASTORIA VETERINARY GROUPATLANTIC ANIMAL CAREBANFIELD PET HOSPITALBANFIELD PET HOSPITAL EAST HARLEMBATH ANIMAL HOSPITALBATTERY PARK VETERINARY HOSPITALBAY RIDGE ANIMAL HOSPITALBAY STREET ANIMAL HOSPITALBAYSIDE ANIMAL CLINICBELLEROSE ANIMAL HOSPITALBIDE-A-WEEBLUEPEARL - BROOKLYNBLUEPEARL - DOWNTOWN MANHATTANBLUEPEARL - MIDTOWNBLUEPEARL - QUEENSBOULEVARD ANIMAL CLINICBOULEVARD VETERINARY GROUPBROADWAY ANIMAL HOSPITAL OF RIVERDALEBRONX COUNTY ANIMAL HOSPITALBRONX VETERINARY CENTERBROOKLYN VETERINARY GROUPCANARSIE ANIMAL HOSPITALCARNEGIE HILL VETERINARIANSCAT PRACTICE VETERINARY HOSPITALCATHEDRAL DOG & CAT HOSPITALCENTER FOR VETERINARY CARECITY VETERINARY CARECLINTON VETERINARY CENTERCOLLEGE POINT ANIMAL HOSPITALCOMPANION ANIMAL NETWORKCOMPLETE CARE VETERINARY CENTERCORONA HEIGHTS ANIMAL HEALTH CENTERDONGAN HILLS VETERINARY PRACTICEDOWNTOWN VETERINARY CLINICDR SINHAS ANIMAL CLINICEAST SIDE ANIMAL HOSPITALFELINE HEALTHFELTON VETERINARY SERVICESFIFTH AVENUE CAT CLINICFIFTH AVENUE VETERINARY HOSPITALFLUSHING VETERINARY MEDICAL CENTERFOREST ANIMAL HOSPITALFOREST HILLS CAT HOSPITALFOUR CORNERS VETERINARY PRACTICEFRESH MEADOWS ANIMAL CLINICFULL PET SERVICESGATEWAY ANIMAL HOSPITAL (VCA)GOTHAM ANIMAL CLINICGRAMERCY PARK ANIMAL CLINICGREATER STATEN ISLAND VETERINARY SERVICESGREENPOINT VETERINARY HOSPITALGREENWICH VILLAGE ANIMAL HOSPITALHEART OF CHELSEA ANIMAL HOSPITALHEIGHTS VETERINARY CLINICHEIGHTS VETERINARY HOSPITALHOPE VETERINARY CLINICHOUSE CALLS FOR YOUR PETHOUSE PET CALLSHOWARD BEACH ANIMAL CLINICINTERNATIONAL ANIMAL CLINICISLAND BIRD CAT & DOG VET GROUPJUNIPER VALLEY ANIMAL HOSPITALKINGS BAY VETERINARY HOSPITALLEFFERTS ANIMAL HOSPITALLENOX HILL VETERINARIANSLEXINGTON VETERINARY GROUP CHELSEA CLINICLIBERTY ANIMAL CLINICLINCOLN SQUARE VETERINARY HOSPITALLOWER EAST SIDE ANIMAL HOSPITALMALIHAN ANIMAL HOSPITALMANHATTAN BEACH ANIMAL CLINICMANHATTAN CAT SPECIALISTSMARINE PARK VETERINARY GROUPMASPETH ANIMAL HOSPITALMERRICK BOULEVARD ANIMAL HOSPITALMIDDLETOWN ANIMAL CLINICMIDTOWN ANIMAL HOSPITALMILLENIUM ANIMAL HOSPITALMOBILE VETERINARY CLINICMOBILE VETERINARY UNITMURRAY HILL ANIMAL HOSPITALNEW YORK VETERINARY HOSPITALNOAHS ARK PET CLINICNOAHS ARK VETERINARY PRACTICENORTH SHORE ANIMAL HOSPITALNORTH_SLOPE VETERINARY, NORTH SLOPE VETERINARYNORTHSIDE ANIMAL HOSPITALNORTHSIDE VETERINARY CLINICNYC MOBILE VETOLIVERS DOG & CAT CLINICONE LOVE ANIMAL HOSPITAL - BAY RIDGEONE LOVE ANIMAL HOSPITAL - BOERUM HILLONE LOVE ANIMAL HOSPITAL - YORKVILLEOZONE PARK ANIMAL CLINICPARK EAST ANIMAL HOSPITALPARK SLOPE VETERINARY CAREPARK SLOPE VETERINARY CENTERPAWS AND CLAWS VETERINARY HOSPITALPET DOCTOR OF FLUSHINGPET HAVEN ANIMAL HOSPITALPETCARE ANIMAL CLINICPROSPECT PARK ANIMAL CLINICPURE PAWS VETERINARY CARE OF CLINTON HILLQUEENS ANIMAL HEALTH AND EMERGENCYQUEENS ANIMAL HOSPITALQUEENS MIDWAY ANIMAL HOSPITALRICHMOND VALLEY ANIMAL HOSPITALRIVERDALE ANIMAL HOSPITALRIVERDALE VETERINARY GROUPRIVERGATE VETERINARY CLINICRIVERSIDE ANIMAL CLINICRIVERSIDE ANIMAL HOSPITALRIVERSIDE VETERINARY GROUPROCKAWAY ANIMAL HOSPITALROSEBANK VETERINARY PRACTICESHEEPSHEAD BAY VETERINARY GROUPSOUTH SHORE ANIMAL HOSPITALST FRANCIS ANIMAL HOSPITALST MARKS VETERINARY HOSPITALST MINA ANIMAL CLINICSTATEN ISLAND VETERINARY GROUPSTEINWAY COURT VETERINARIANSSUNNYSIDE PET HEALTHCARE CENTERSUTTON VETERINARY GROUPSYMPHONY VET CENTERTHE DOG AND CAT DOCTORTRIBECA SOHO ANIMAL HOSPITALTRIBORO ANIMAL HOSPITALTRYLON VET CAREUNIVERSITY ANIMAL HOSPITALURBAN VETSVCA MANHATTAN VETERINARY GROUPVETERINARY CARE UNLIMITEDVETERINARY EMERGENCY & REFERRAL GROUP NORTHVETERINARY EMERGENCY & REFERRAL GROUP SOUTHVETERINARY INTERNAL MEDICINE & ALLERGY SPECIALISTSVICTORY VETERINARY PRACTICEVILLAGE VETERINARIANVISITING VET OF NYWASHINGTON SQUARE ANIMAL HOSPITALWEST CHELSEA VETERINARY HOSPITALWEST VILLAGE VETERINARY HOSPITALWESTSIDE VETERINARY CENTERWHITESTONE ANIMAL HOSPITALWHITESTONE VETERINARY CAREWILLIAMSBURG ANIMAL CLINICWINDSOR TERRACE VETERINARIANSWOODSIDE PET HOSPITALWORTH STREET VETERINARY CENTER
	If other, please enter facility name
	If other, please enter facility address
	Phone number 1 * must provide value
	Phone number 2
	Report date	TodayM-D-Y
	Primary veterinarian or caretaker of animal
	Borough	Bronx Brooklyn Manhattan Queens Staten Island Unknown reset
PATIENT INFORMATION
	Patient name
	Patient medical record number (if available)
	Species	Cat Dog Other reset
	If other please specify
	Approximate age (specify if age is in years or months)
	Onset date (may be approximate)
	Disposition	Alive Dead reset
NOTES
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