Veteran Service Dog Application 🐾🇺🇸
Please complete all required sections to apply for a service dog.
Section 1: Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Address
*
Section 2: Military Service
Branch of Service
*
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Other
Dates of Service (From)
*
-
Month
-
Day
Year
Date
Dates of Service (To)
*
-
Month
-
Day
Year
Date
Rank at Discharge
Type of Discharge
*
Please Select
Honorable
General
Other than Dishonorable
Upload DD214 (PDF, JPG, or DOCX)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Section 3: Service Dog Needs Assessment
Type of Support Needed
*
Mobility Support
PTS Support
Both
Describe your daily challenges and limitations
*
How do you believe a service dog will improve your quality of life/function?
*
Upload supporting statement (Optional)
Upload a File
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Choose a file
Cancel
of
Section 4: Medical Provider Documentation
Provider Specialty
*
Mental Health
Orthopedics
Neurosurgery/Neurology
PM&R
Upload Provider Letter
*
Upload a File
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Choose a file
Cancel
of
Letter must confirm the veteran has completed all prescribed treatment and that a service dog would improve quality of life/function (38 CFR 17.148).
Section 5: Living Situation, Readiness & Veterinary Care
Do you currently own pets?
*
Yes
No
Describe your pets
Do you have the ability to care for a service dog (feeding, grooming, exercise)?
*
Yes
No
Describe your daily routine
*
Do you have an established veterinarian?
*
Yes
No
Clinic Name
Veterinarian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you willing/able to establish veterinary care?
Yes
No
Are you financially able to support routine and emergency veterinary care?
*
Yes
No
Do you understand ongoing veterinary care is your responsibility?
*
I understand ongoing veterinary care is my responsibility
Are you willing/able to travel to work with a trainer if required?
*
Yes
No
Section 6: Consent & Acknowledgment
I certify that all information provided is true and accurate.
*
I certify that all information provided is true and accurate
I understand submission does not guarantee funding or acceptance.
*
I understand submission does not guarantee funding or acceptance
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
Section 7: Internal Scoring (Reviewer Only)
Clinical Need (mobility/PTS severity, provider recommendation)
Clinical Need Notes
Veteran Insight & Motivation (personal statement clarity, commitment)
Veteran Insight & Motivation Notes
Readiness & Environment (routine, household, ability to care for dog)
Readiness & Environment Notes
Veterinary & Financial Preparedness
Veterinary & Financial Preparedness Notes
Program Fit & Safety
Program Fit & Safety Notes
Bonus / Priority Considerations
Bonus / Priority Considerations Notes
Total Score
Reviewer Recommendation
Strong Candidate
Consider
Not Appropriate
Reviewer Notes
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