Service Dog Application

Service Dog Application
Applicant's Full Name*
First and last name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant’s Date of Birth*

MonthDayYear
Date
Applicant’s Age*
Is applicant a minor?*

YesNo
Is the applicant a veteran or current/former public-safety professional (such as law enforcement or fire service)?*

YesNo
Parent/Guardian Name*
Primary Contact Email*
example@example.com
Primary Contact Phone*

Area CodePhone Number

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.)?*

Household Information & Dog Care