Application for a Service Dog

Basic Information

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Dog of Interest

Is everyone in the home on board with having a dog in the home?

Does you or anyone in your home have dog allergies?

Please list everyone in your home including name, age, and relationship,

Medical Information

Physician's Name

(For Diagnosis Verification)

May We Contact Your Physician?

(For Diagnosis Verification)

Physician's Phone

(For Diagnosis Verification)

(###)

###

####

Physician's Address

(For Diagnosis Verification)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What are your diagnoses?

What tasks do you believe you could benefit from?

What are your daily limitations due to your disability(s)?

Do you have any restrictions/precautions as a result of your diagnoses?

What types of adaptive equipment do you use?

Employment

Are you employed?

Employer

May We Contact Your Employer?

Employer's Phone Number

(###)

###

####

Basic Job Duties

Living Situation

Type of Home

Own or Rent

Landlord's Phone Number (if rent)

(###)

###

####

Do you have a fenced yard?

How do you plan to exercise your dog?

Pet Information

Do you have any other pets?

List all pets (include species, name, age, sex, size and if they are fixed)

Where does each pet reside?

inside or outside

Are all pets up to date on vaccines?

Have you had to re-home a pet?

If yes, please explain

Have any of your previous pets died of unnatural causes?

If yes, please explain

Veterinarian Information

Veterinarian Name

Veterinarian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Veterinarian Phone Number

(###)

###

####

Financials

Our service dog families are expected to maintain a high level of care with their service dog. It is expected that your dog will be fully up to date on all medical care, provided a high quality diet, maintain a healthy weight and be properly groomed. To accomplish this expectation requires a family to be prepared for a cost around $2,000-3,000 each year for their service dog.

Are you financially able to care for a dog?

How will you/your family pay for the dog?

Are you physically able to meet your dogs grooming requirements?

If not, please explain how the dog will be groomed

Thank You for Your Application

Providing Pawsable reserves the right to deny services to any applicant which doesn’t meet the criteria necessary for placement of a service dog or who requires services not trainable within the guidelines of the training facility.