Service Dog

Service Dog Customization

The information contained in this application is used only for the purpose of ensuring proper standards for your service dog and its training. This form is private to only the trainer. Completing this form is one step closer to your perfect dog.
Full Legal Name*

First NameLast Name
Preferred Name / Nickname

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Profession
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number - Home*

Area CodePhone Number
Phone Number - Cellular

Area CodePhone Number
Emergency Contact Name*

First NameLast Name
Emergency Contact Relation *
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Email*
example@example.com
Disability & Medical Information

This helps us determine what type of training you would benefit from.
What is your primary disability?*

Mobility ImpairmentVisual Impairment/BlindnessHearing Impairment/DeafnessPsychiatric/Mental Health ConditionAutoimmune DisorderSeizure DisorderDiabetes / Medical ImbalanceAutism Spectrum DisorderPTSDCardiac ConditionNeurological DisorderOther
Is your condition:*

StableProgressiveEpisodicOther
Primary Care Physician Name

First NameLast Name
Physician Phone Number

Area CodePhone Number
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Can your physician provide documentation of your disability?*

YesNo
Are you willing to sign a medical release form?*

YesNo
Are you currently receiving treatment for your disability?*

YesNoIn the future
What treatment are you receiving?
What have been your biggest struggles? *
Do you use any mobility aids?*

Wheelchair (Manual)Wheelchair (Power)WalkerCaneCrutchesProstheticsNoneOther
What is the biggest challenge preventing you from getting a service dog at this time?*
Lifestyle:
With these questions, we will be able to pick the right puppy for you.
Do you live in a:*
Household Setting*

RuralSuburbanUrban
Do you have children at home?*

YesNo
Does anyone in your household have allergies to animals?*

YesNo
Have you owned a dog before?*

YesNo
Do you have any pets?*

YesNoI will soon!Other
What pets / animals will your service dog be interacting or living with? (If none, write N/A)*
What gender are you looking for?*

MaleFemaleNo Preference
What are your breed preferences?*

Golden RetrieverLabrador RetrieverGerman ShepherdStandard PoodleLabradoodle/GoldendoodleRough/Smooth CollieBernese Mountain DogGreat DaneBoxerAustralian ShepherdOther
Do you have a color or aesthetic preference? (We can't always guarantee this because we are ensuring temperament first, however we will do our best to match your dog as closely to this as possible.
Do you have a fenced yard?*

YesNoPartial
Do you work outside of the home?*

YesNo
Do you want to pick up your service dog from us? (We are located in Las Vegas, Nevada)*

YesNo
Would you like to have your service dog delivered?*

YesNo
Will you be visiting your service dog during it's training?*

YesNoPossibly!
Describe your typical daily routine in detail. (Sleep schedule, activities, outings, ect)*
How often do you go out of the house?*

Every Day (6-7 days a week)Every Other Day (4-5 times a week)Sometimes (3-4 times a week)Hardly (0-3 times a week)
What types of environments will your dog be working in regularly?*

Grocery StoresResturauntsMedical Facilities / HospitalsPublic TransportationPrivate TransportationCrowded EventsQuiet Office SettingsSchool / UniversitiesOther
Where do you want your dog to sleep?*

In the bed with meOn the floor in my bedroomIn a crate in my bedroomIn a crate not in my bedroomOther
Do you want your dog to be allowed on furniture?*

No.Yes, but only specific furniture.Yes, all furnitureOther
Are there any rooms / places in your home that your dog is not allowed? (ie kitchen, bathroom, ect)*
Do you want your dog to give you kisses?*

Yes, anytime.Only when asked for it.No, neverOther
Do you want your dog to jump on you?*

Yes, but only when invited.No, never.Other
How much physical affection do you want from your dog when they are off duty?*

Very Affectionate (Cuddly, close contact)Moderately Affectionate (Only when invited)Minimal Affection (When being praised)
Do you want your dog to greet strangers in public?*

No, Never.Only when released to go say hi.Yes friendly but controlledOther
What side do you want your dog to walk on?*

Left SideRight SideEither Side (Flexible)Behind Me (Closely)
Are there any commands or behaviors you do NOT want trained into your dog?*
Are there any commands or behaviors you DO want trained into your dog?*
Such as "Hug" for DPT
Do you want your dog to respond to multiple handlers or just you?*
How commanding are you?*

Very Soft / Minimal Correction (I want my dog to be extremely sensitive and respond to the smallest cues. I prefer whisper-quiet commands, subtle body language, and minimal corrections. I don't want to raise my voice or be firm at all.)Gentle / Quiet Commanding (I want my dog to respond easily to quiet, calm commands. I prefer a soft tone and gentle corrections. I'm comfortable giving clear direction but don't want to be loud or stern)Moderate / Balanced Commanding (I want a dog that responds to normal conversational commands but can also handle occasional firmness when needed. I'm comfortable being clear and direct without being harsh.)Firm / Confident Commanding (I'm comfortable being assertive and direct with my dog. I want a dog that responds well to confident, clear commands and can handle a firmer tone when needed.)Very Assertive / Strong Commanding (I have a naturally commanding presence and want a dog that can handle strong, direct leadership. I'm comfortable being very firm and expect immediate obedience.)Variable / Situational (My commanding style varies depending on the situation. I may be soft at home but need to be firmer in public, or vice versa.)Other
What energy level do you prefer for your service dog?*

High Energy (active, playful, encouraging)Moderate Energy (Balanced)Low Energy (Relaxed, CalmOther
Are there any behaviors you absolutely cannot tolerate in a service dog?*
What color / theme do you want for your service dog?*

Standard Blue Service Dog SetCustom ColorThemed Gear (floral, fruit, galaxy, ect)Minimalist / PlainOther
If you chose customization or have other notes, please add them here.
Do you prefer a harness, vest, or both?*

HarnessVest / CapeBothOther
Do you want patches on your vest/harness? If so what should they say?*

"Service Dog""Do Not Pet""Medical Alert Dog""Psychiatric Assistance Dog""Mobility Service Dog""Multi-Purpose Service Dog""Ask to Pet""No Talk, No Touch, No Photos"I do not want patches.Other
Do you have any specific gear requirements? (ie. handle for mobility support, pockets for supplies, ect)*
Is there a specific timeline for when you need your service dog?
Is there anything else you would like us to know about your needs, preferences, or lifestyle?
By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully. I also agree that the customization options are of my preference.
Date*

MonthDayYear
Your name*
E-mail*
Congratulations for taking the next step towards independence. Thank you again, for working with Nose For Success. We will be speaking with you shortly to confirm. :)
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Service Dog Customization

Disability & Medical Information