Service Dog Application

Patient's First Name *

Patient's Last Name *

Patient's Email *

Patient's Date of birth *

Mobile Phone *

Other Phone

Address *

City *

State *

Postal code *

Occupation *

Patient's Gender

Male

Female

Marital Status *

Marital Status

Single
Married
Widowed
Separated
Divorced
Domestic Partner
Other
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Children *

Are there children in the house?

Yes
No
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Other Dogs? *

Other non-canine animals *

Best Time to Reach You?

How did you hear about us?

Medical History

Date Diagnosed

Other Household Members with Tobacco Use

Does anyone else in the household use tobacco in any form?

Yes
No
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Tobacco Use

Do you use tobacco in any form?

Yes
No
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Tobacco Use Frequency

Diabetic Ketoacidosis

Have you ever been hospitalized due to Diabetic Ketoacidosis?

Yes
No
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Hospital Stays?

Hospital Stays outside of DKA?

Have you ever been hospitalized due to anything other than DKA or an injury?

Yes
No
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Hospital Stays Outside of DKA or Injury?

Recent A1C?

Other Diabetics within the house?

Is anyone else (other than the applicant) in the household a diabetic?

Yes
No
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Endocrinologist Care?

Are you currently under the care of an endocrinologist?

Yes
No
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Endocrinologist Last Visit?

Any allergies to Dogs?

Is anyone in your household allergic to dogs?

Yes
No
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Allergies?

Do you have any allergies?

Yes
No
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Allergy List

Prior Service Dog?

Have you ever owned a service dog?

Yes
No
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Current Service Dog?

Do you currently own a service dog?

Yes
No
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Other Service Dog Organizations?

Emergency Contact

Full Name

ER Contact Relationship to Patient?

ER Contact Phone

ER Contact Address