Service Dog Application

Name *

First

Last

Street Address *

Apt/Bldg #

City *

State *

Zip Code *

Phone

Email *

Applicant's Current Age *

Applicant's Date of Birth *

Parent's Name (If Applicant is a Minor)

Parent's Email

Parent's Phone

All Household Members living with Applicant and their Age

Do any Household Members have a dog allergy?

Do any Household Members have a fear of dogs?

Primary Care Physician

Practice Name

Practice Phone

Practice Address

Practice Apt/Bldg #

Practice City

Practice State

Practice Zip Code

Have you signed a Release of Information for the Provider listed above?

Therapist

Physical Therapist (If Applicable)

Therapist Practice Name

Therapist Practice Phone

Therapist Practice Address

Therapist Practice Apt/Bldg #

Therapist Practice City

Therapist Practice State

Therapist Practice Zip Code

Occupational Therapist (If Applicable)

Practice Name

Practice Phone

Practice Address

Practice Apt/Bldg #

Practice City

Practice State

Practice Zip Code

Applicant Diagnosis

Primary Medical Diagnosis

Secondary Medical Diagnosis (If Applicable)

Primary Psychiatric Diagnosis (If Applicable)

How does the Diagnosis affect daily life

What are the Cognitive and/or Physical Limitations

Are 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 for

What, 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 knowledge

Name of person filling out Application *

Relationship to Applicant *

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