Monthly Follow Up

Service Dog/Facility Dog Monthly Follow-Up

2928 East Conway RoadCenter Conway, NH 03813
The completion of this form is in keeping with your agreement to the follow-up policy of ACTS for ACTS placed dogs. Failure to complete and submit this form in a timely manner may result in suspension of ACTS certification.

Please take a moment to answer the following questions.
IMPORTANT INSTRUCTIONS: Please read carefully

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This form MUST be filled out in one session. If you leave the session, the form will NOT be saved.
Client
Date*

MonthDayYear
Date
Client Name*
Dog Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Follow-Up Questions
Please Choose One*

We are doing well and having no issues. There is no reason to contact me at this time.I have some questions. Please contact me.
If you would like us to contact you, please give us a good time to call you.*
I continue to provide routine veterinary care including check-ups and vaccines.*

YesNo
If no, please explain.
I continue to provide adequate nutrition through proper diet and clean water at all times.*

YesNo
If no, please explain.
My dog is the proper weight.*

YesNo
If your dog is not the proper weight, please explain.
I continue to provide daily exercise and regular bathing and grooming.*

YesNo
If no, please explain.
Is there anything else you want to tell us?
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*

Clear
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Service Dog/Facility Dog Monthly Follow-Up