| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| Phone |
|
| Best time/way to contact you? |
|
| Email |
|
| Is the dog for you or a family member? |
|
| If other than you, who in the family? |
|
| What is the age of the person? |
|
| Do you have other pets? |
|
| If so, what do you have and how many? |
|
| Dog/Cat |
|
| Age |
|
| Spay/Neutered |
|
| Have you ever owned a service dog? |
|
| If so, from what organization? |
|
| Describe your lifestyle (work, activity level, social activities—clubs, sports) |
|
| Will the dog accompany the person to school/work outside of the home? |
|
| What modes of transportation do you use for commuting? |
|
| Describe where you live? (neighborhood, city, country, farm, house, apartment, townhouse, one-story, two-story, three-story, fenced yard, access to grassy/wooded area, paths/sidewalks) |
|
| How many adults/children are in the home? |
|
| Age/Relationship? |
|
| Describe any disabling medical conditions, including Type 1 or 2 diabetes |
|
| Does anyone in the home suffer from dog allergies? |
|
| Does anyone in the home smoke? |
|
| Have you discussed getting a service dog with your doctor? |
|
| What is your current A1c? (Optional) |
|
| Comments (Optional) |
|
| |
| |
