Patient Name

Date

Email (required)

Phone Number (required)

Date of Birth

Age

Address / City / State / Zip

What is the reason for your visit? Please describe your medical complaint?

Current Medications You Are Taking Now:

Please list any treatments you have had for your current medical condition (e.g. surgeries, physical therapy, acupuncture, homeopathy, psychiatric care):

Is your medical condition ongoing/chronic?
YesNo

Do you have any of the following chronic illnesses? Please check all that apply:
Asthma or COPDHIVHeart TroubleAcne or other skin conditionsStomach UlcersMultiple Sclerosis (MS)GERD (Acid Reflux)Anxiety or DepressionHypertensionHeadacheAutoimmune or Connective Tissue Disease(ie: Rheumatoid Arthritis,HerpesCancer

Service Animal Information:

What type of animal is your service animal? (dog, cat):

What breed is your animal?

Does your animal help treat or alleviate your disability?

What service is your animal trained to provide you?

I am requesting a service animal letter from a doctor for this reason:

Do you need an air travel service animal letter for an additional $10?
YesNo