Diabetic Alert Dog Application

PLEASE DO NOT BEGIN THIS APPLICATION UNTIL YOU HAVE WATCHED THE VIDEO "HOW TO GET A DIABETIC ALERT DOG. THE STEP BY STEP PROCESS"

This video explains in great detail the process of getting a service dog from us, and you should be familiar with this process before applying. You can find the video on our website or our youtube channel. Thank you.

Did you watch the video on our website or youtube channel titled: "How To Get A Diabetic Alert Dog. The Step By Step Process"

Patient Name

TitleFirst NameMiddle NameLast Name

Preferred Name

Patient Gender

Spouses Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Patient Birth Date

MonthDayYear

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Patient E-Mail

Occupation

Are you a full-time student at a college?

If yes, name of college

Marital Status:

Please Describe Your Housing:

Do you have other dogs at home? If yes please please list name, age, breed, sex, and neutered or spayed.

How did you hear about our organization?

Please check your preferred method of contact:

Name

Relationship

Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date you were diagnosed with type 1 diabetes.

MonthDayYear

Do you use tobacco in any form?

If yes, please list type and frequency of use

Does anyone else in the household use tobacco in any form?

Is anyone in your household allergic to dogs?

Have you ever been hospitalized due to Diabetic Ketoacidosis?

If yes, please describe number of times and length of visits.

Have you ever been hospitalized due to anything other than DKA or an injury?

If yes, please describe number of times and length of visits.

Is anyone else (other than the applicant) in the household a diabetic?

Are you currently under the care of a endocronologist?

Date of last visit

MonthDayYear

Your most recent A1C

Do you have any allergies?

If yes, please list

Have you ever owned a service dog?

Do you currently own a service dog?

If yes to either of the above please list the name of the organization/s you've worked with previously to obtain your SD.

Please describe your ideal service dog. You may include things such as breed, color, sex, and of course your expectations of how the dog will assist you.

I, the undersigned, certify that I (or my dependent) have filled out this form to the best of my ability. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my answer status.

Responsible Party Signature: ___________________________________ Date:______________

(The signature above will be physically signed when you visit the office.)

Diabetic Alert Dog Application

Emergency Contact

Medical History