Service Dog Application

Medical Providers & Health Information
Primary Care Physician Name*
Practice Name*
Provider Phone Number*
Provider Address*
Provider City*
Provider State / Province*
Provider Postal / Zip Code*
Other Medical Providers (Therapists, Specialists)
Have you signed a release of information for the listed provider(s)?*

YesNo
Medical Diagnoses (Primary and Secondary)*
Psychiatric Diagnoses (if applicable)
List all medications the applicant is taking and their purpose*
How does the applicant’s diagnosis affect daily life (including cognitive, physical, or other limitations)?*
Any restrictions or precautions we should know? *
Is the applicant currently receiving medical treatment? Such as physical therapy, counseling, medications, surgeries, infusions, etc.*

YesNo
What treatments are they receiving?
What, if any, adaptive equipment does the applicant use (speech, hearing, mobility, etc.)?*

Final Confirmation
Name of Person Completing This Form*
How did you hear about Canines for Change?*
I confirm all information provided is true to the best of my knowledge
Signature:*

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Relationship to Applicant*
Date:*

MonthDayYear
Date
Thank you for taking the time to complete this application!

Our team will review it and reach out within 7 business days. We appreciate your interest and look forward to connecting with you soon!

If you’d like more information about the process in the meantime, please visit our website.
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Household Information & Dog Care