Phone Number (required)
Date of Birth
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?
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: