ESArecs Form 1

1
What is your full name?* This field is required.Your name must match the verification ID you submit.
First Name
Last Name
2
What is your email?* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code? or
Receiving the email may take a few minutes, thank you for your patience!
3
What is your birthdate?* This field is required.You must be over the age of 18 years to continue.
Date of Birth
Month
Day
Year
4
Are you currently in the State of California?* This field is required.While you do not have to be a California resident, you are required to be within the state borders of California to be evaluated. Also, the letter you receive from us is only valid in the State of California.
YESNO
5
What is your phone number?* This field is required.
Please enter a valid phone number.
6
Does the phone number {whatIs7} receive texts? * This field is required.
YESNO
7
Do you have stable internet access to support a 10-15 minute Telehealth video conference session with one of our doctors via Zoom?* This field is required.
YESNO
8
May our doctor call you at {whatIs7} to evaluate you and determine if you qualify to receive an Emotional Support letter for your dog?
YESNO
9
Each pet is required to have its own ESA letter. Would you like to obtain multiple letters for your additional pets?Each additional ESA letter is discounted to $65.
YESNO
10
Please tell us about your pets.OPTIONAL
11
Please select a time for your Telehealth consultation with one of our licensed Medical Doctors in the State of California.* This field is required.
12
Please upload an image of a valid government ID.* This field is required.Acceptable form of IDs include an ID cards or Driver License from any State, passport, or Visa.
Drag and drop files here
Select files to upload
Cancelof
13
PaymentIf you would like to get a Psychiatric Service Dog (PSD) letter, you will have the opportunity to upgrade in the next section, only if you qualify. Remember, if you are not approved, you'll be fully refunded!
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
MD Evaluation for ESA LetterA licensed Medical Doctor will evaluate you via telemedicine to determine if you qualify for an Emotional Support letter for your dog. If you do not qualify, you will receive a full refund!
$100.00Edit
Back
Extra ESA letter for an additional petGet additional ESA letters for each pet in your home.
$65.00Edit
Back
Express MD Consultation (within 30 minutes)You'll move ahead in the queue and your online consultation with a doctor will happen in the next 30 minutes.
$50.00Edit
Back
Enter Coupon
Total cost $0.00
First Name
Last Name
14
1. I hereby authorize ESArecs.com to use the Online Health Questionnaire as the initial component of a telehealth practice platform for the evaluation of my medical condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. I understand that my current insurance will not cover the fees associated with the telehealth service and I will be responsible for payment of the fee out of pocket.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

Click NEXT below to continue.
15
By signing below, I acknowledge that I understand an emotional support animal does not qualify as a SERVICE animal, and that knowingly and fraudulently representing the animal as a service animal is a misdemeanor violation of Section 365.7 of the Penal Code.* This field is required.SIGN BELOW
Clear
16
By signing below, I am providing consent to use telehealth technology for my medical evaluation. I also declare under penalty of perjury that the information I provide on this form and the subsequent forms to follow are and will be true and correct.* This field is required.SIGN BELOW
Clear
17
Terms and Conditions* This field is required.
18
Thank you! You're almost done with Part 1 of the questionnaire. As a reminder, your appointment with one of our doctors for your Telehealth consultation is scheduled for the time and date listed below:After you submit this form, you will receive a confirmation email from Zoom with the link for you to connect.
Date
Month
Day
Year
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
19

You have successfully completed PART 1 of the online health questionnaire.

Once you submit this form, you will be automatically redirected to PART 2.

You must complete PART 2 before your online consultation with a doctor.

Click the SUBMIT button below.
Should be Empty: