General Patient History - Service Animal Telehealth

In order to qualify, your animal must be trained to provide you with a medical service or task. Providing emotional support and/or comforting will not qualify.

Initial Below

The following information is necessary. Please answer all questions to the best of your knowledge.










    Asthma or COPDFaintingDiabetesHIVHeart 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:

    Appointment Booking Form:

    Fill your details to book your appointment.

    Appointment Booking Form:

    Fill your details to book your appointment.

    Appointment Booking Form:

    Fill your details to book your appointment.