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 Contact You?

Best Time for us to contact you?

7am - Noon
Noon - 5pm
5pm - 8pm
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How did you hear about us?

Medical History

Date Diagnosed

Other Household Members with Tobacco Use

Does anyone 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 for Diabetic Ketoacidosis?

Yes
No
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Hospital Stays

Hospital Stays Outside of DKA

Have you ever been hospitalized for other than Diabetic Ketoacidosis 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 house 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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Any Allergies

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