Medical Form Service Dogs

Medical Form - 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
IMPORTANT INSTRUCTIONS: Please read carefully

Please use your TAB key to move on to the next entry box.

This form MUST be filled out in one session. If you leave the session, the form will NOT be saved.
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 Service Dog Program Our organization is a non-profit agency that trains and places service dogs that assist with mobility impairment.
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.*
If the applicant has 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 to place a dog 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 restricted in the use of their hands or arms?*

yesno
If yes, please explain.
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 ackowledge 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 - Service Dogs