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:*

Powered by Jotform SignClear
Relationship to Applicant*
Date:*

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

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

If you’d like more information about the process in the meantime, please visit our website.
Should be Empty:

Household Information & Dog Care