Healthcare ESA Release

HEALTHCARE ESA RELEASE

Facility Name:

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Insurance Information

Policy Number:    Group Number:

Medical History

Emotional Support Animal (ESA) Information

Animal Name:    Species: Dog Cat Other

Breed / Description:    Age:

Vaccination Records Provided: Yes    Date of Last Vaccination:

Veterinarian Name:    Vet Phone:

Accommodation Request and Purpose

Authorization Expiration Date:

Acknowledgments, Release, and Certifications

I certify that the information provided in this form is true and complete to the best of my knowledge. I acknowledge that the facility may require verification of vaccination and licensing records and that false statements may result in denial or immediate revocation of ESA access.

Assumption of Risk: I understand that the presence of an animal carries inherent risks, including allergic reactions, scratches, bites, and transmission of zoonotic disease. I voluntarily assume all such risks arising from the ESA's presence within the facility.

Release and Waiver: Except in cases of the facility's gross negligence or willful misconduct, I hereby release, waive, discharge, and covenant not to sue the facility, its governing body, agents, employees, contractors, volunteers, and representatives from any and all liability, claims, demands, causes of action or suits arising out of or related to any loss, damage, injury, or illness (including death) to persons or property caused by or resulting from the presence of the ESA.

Indemnification: I agree to indemnify, defend, and hold harmless the facility and its agents from any claim, demand, loss, liability, damage, or expense (including reasonable attorney fees) arising out of or resulting from the ESA's actions or failure to comply with facility rules.

Control and Responsibility: I agree that the ESA will be under my control at all times, kept on a leash, harness, or in an appropriate carrier unless otherwise required for disability-related reasons. I am responsible for cleaning up after the ESA and for any damage the ESA causes to facility property.

Immediate Removal: I acknowledge that the facility may require immediate removal of the ESA for disruptive behavior, threats to safety, sanitation concerns, or noncompliance with facility policies. The facility's determination may be acted upon without prior notice to me.

Medical Information Release for Accommodation: I authorize the release of limited medical information to designated facility staff as necessary to evaluate and administer the ESA accommodation. I understand my broader medical privacy rights under applicable law and that this authorization is limited in scope to ESA accommodation needs.

Revocation: I may revoke this authorization in writing at any time, except where the facility has already taken action in reliance on this authorization. The facility may also revoke accommodation if continued presence of the ESA creates a direct threat or fundamental alteration of services.

Emergency and Veterinary Authorization

In the event the ESA requires emergency veterinary care while on facility premises and I am unavailable to authorize treatment, I authorize the facility to obtain necessary veterinary treatment at my expense and to act reasonably to protect the health and welfare of the animal. I agree to reimburse the facility or any third party for the cost of such care.

Additional Consents and Notices

Communication: I consent to facility staff communicating necessary information regarding ESA accommodations to staff members directly involved in my care. This limited disclosure is intended solely to implement and monitor the accommodation.

Visitor Policy Acknowledgment: I understand that this release does not override general facility policies regarding visitors, infection control, or any applicable public health requirements. ESA access may be restricted in certain clinical areas for clinical or safety reasons.

Certification

By signing below, I certify under penalty of perjury that I am either the patient named in this form or the authorized legal representative of the patient, that I have read and understand this Healthcare ESA Release, and that I accept the responsibilities and risks described herein.

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