Patient Name
Date
Phone Number (required)
Date of Birth
Age
Address / City / State / Zip
How did you hear about us (internet, walking by, referral, print ad)?
Can we contact you with news, discounts, and/or renewal reminders? YesNo
Email (required)
Are you a new patient or a renewal?
Are you using your ESA letter for any of the following? (If yes, there will be a $10 fee per form/modified letter.) Please check all that apply: HousingWorkplace (CA residents only.)Air CanadaLatamVolarisWestjetInternational Air Travel
Please list all medical conditions you have:
Current Medications You Are Taking Now:
Do you have any of the following? Please check all that apply: AnxietyDepressionPanic AttackPost Partum DepressionPhobias/FearsBi-PolarPTSDPersonality DisorderInsomniaObsessive Compulsive DisorderOther
Without your animal, which “major life activity(s)” are limited by your disability Caring for one’ selfSocializingLearningWorkingSleepingOther
Please list any treatments you have had for your current medical condition above (including psychiatric care, counseling homeopathy, etc.):
Emotional Support Animal Information:
Animal Name:
Animal Breed:
Animal Type (e.g. Dog, Cat)
Animal Color:
Animal Age:
Sex of Animal:
Weight and Height of Animal:
