ESA Letter Submission

ESA Letter Submission

Submit your Emotional Support Animal (ESA) letter and related information here.
Please complete the information below to request an Emotional Support Animal (ESA) letter. A non-refundable fee of $50.00 is required for the preparation of the letter. Your request will be processed after all required information has been received and payment has been made.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Please select one of the following options to indicate how you would like your ESA letter delivered:
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Pet Type
Pet Name
Pet Breed
Pet Color
Pet Weight
Enter the pet's weight in pounds or kilograms.
Complex Name
Please select one of the following options to indicate when you need your ESA letter:
Signature
Disclaimer: Submission of this request does not guarantee that the requested form or letter will be completed. The decision to complete any form or letter is at the discretion of the patient’s provider and will be based on the provider’s clinical judgment, available information, and applicable policies.
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