I attest that the information on this form and any medical history presented to the doctor is factual and complete.

I confirm that my animal provides therapeutic emotional support with respect to my disability.

I will not discontinue medications, therapies, and other forms of treatment upon qualifying for an Emotional Support Animal letter unless suggested by my PCP.

I will return to New Leaf Wellness Center for a follow up visit within 3 months. If I am unable to return to New Leaf Wellness Center then I will visit with my PCP or specialist.

I understand that upon qualifying, my letter will be valid for one year and I must be reevaluated by New Leaf Wellness Center to maintain an ongoing and therapeutic relationship.

I understand if my animal exhibits any unsafe and/or disruptive behavior, my animal may be refused and asked to leave.

I understand that I am financially responsible for any damages resulting from the actions of my animal.

I acknowledge that New Leaf Wellness Center is not responsible for my animal’s behavior.

Patient Signature
Clear

Date