Medical Form Owner Trained Service Dogs

Medical Form - Owner Trained Service Dogs

This form is to be filled out by a physician to confirm the applicant's disability
ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org
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Applicant
Today's Date*

MonthDayYear
Date
Applicant Name*

First NameLast Name
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Phone*

Area CodePhone Number
Applicant Height *
Applicant Weight*
The above applicant has applied for our Owner Trained Service Dog Program Our organization is a non-profit agency that trains and places service dogs that assist with mobility impairment. We also offer owner trained service dog programs.
Physician
Your Name*

First NameLast Name
Medical Specialty*
Medical Facility Name*
Medical Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone *

Area CodePhone Number
Medical Information
Do you think that a service dog would be beneficial to the applicant?*

YesNo
Please explain.*
Is the applicant able to use their hands and arms to handle a dog on a leash, including tasks like guiding, directing, and providing commands?*

YesNo
If the applicant has other physical disabilities or conditions that affect them and/or limit them physically, what are they and how do they affect the applicant?*
Does the applicants physical disabilities or conditions that affect their mental or cognitive condition (i.e. memory retention, concentration or understanding)? If so, please explain in as much detail as possible.*
Does this person have a stress related or mental health disability?*

YesNo
If yes, please list the diagnosis and explain how it affects the applicant.
Does the applicant have a disability in which they lose control and might injure a dog or provoke a dog into defending itself?*

yesno
In your professional opinion, is it safe for a dog to be with this person (Please take into account the safety of the person and of the dog.)?*

yesno
Please explain in detail if you have any concern about the use of a service dog for this person.*
Is the applicant able to give voice commands?*

yesno
If no, please explain.
Are ther any special considerations we should be aware of?*
Do you have any further comments?
I acknowledge that by submitting my name and signing below, that all the above information is accurate.
Name*

First NameLast Name
Please Sign and Submit*

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Medical Form - Owner Trained Service Dogs