Service Dog ApplicationPlease enable JavaScript in your browser to complete this form.Name *FirstLastStreet Address *Apt/Bldg #City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *PhoneEmail *Applicant's Current Age *Applicant's Date of Birth *Parent's Name (If Applicant is a Minor)Parent's EmailParent's PhoneAll Household Members living with Applicant and their AgeDo any Household Members have a dog allergy?Do any Household Members have a fear of dogs?Primary Care PhysicianPractice NamePractice PhonePractice AddressPractice Apt/Bldg #Practice CityPractice StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPractice Zip CodeHave you signed a Release of Information for the Provider listed above?YesNoTherapistPhysical Therapist (If Applicable)Therapist Practice NameTherapist Practice PhoneTherapist Practice AddressTherapist Practice Apt/Bldg #Therapist Practice CityTherapist Practice StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingTherapist Practice Zip CodeOccupational Therapist (If Applicable)Practice NamePractice PhonePractice AddressPractice Apt/Bldg #Practice CityPractice StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPractice Zip CodeApplicant DiagnosisPrimary Medical DiagnosisSecondary Medical Diagnosis (If Applicable)Primary Psychiatric Diagnosis (If Applicable)How does the Diagnosis affect daily lifeWhat are the Cognitive and/or Physical LimitationsAre there any Restrictions or Precautions we should be aware of?Is the Applicant currently receiving Medical Treatment?If Yes, what Treatments are they receiving?List all Medications the Applicant is taking and what they are forWhat, if any, Adaptive equipment is Used for Speech, Hearing or Other?Who will be the Primary Caregiver for the Dog?Is the Applicant physically able to handle the Dog alone?If No, can the Applicant of the Service Dog assist with the care of the Dog?Are you financially able to provide food, veterinary care, and grooming for the dog?Is everyone in the household aware that a working Service Dog is not a pet and must be treated as a working dog and not a pet?Does Applicant have a fenced in yard, either physical or electric?What would be the greatest benefit to having a Service Dog?Where would the Service Dog be required to go on a normal day?If the Applicant is a child, would a Service Dog be going to school?How do you feel a Service Dog would benefit the Applicant at home?Confirm information accuracy *I confirm that all the above information is correct to the best of my knowledgeName of person filling out Application *Relationship to Applicant *Submit