Healthcare Service Dog Form

HEALTHCARE SERVICE DOG FORM

Patient Information

Date of birth:    Gender: Male Female Non-binary/Other Prefer not to say

Insurance / Billing (if applicable)

Service Dog Details

Breed:    Age:    Sex:

Training status: Public access trained Task-specific trained Trained for household only Currently in training

Mobility assistance (balance, brace) Item retrieval Medication or seizure alerts Psychiatric/psychological support Other (describe below)

Veterinary and Vaccination Information

Last veterinary exam:    Vaccination records available:

Rabies   
Distemper/Parvo   
Bordetella   
Other   

Medical Justification and Functional Need

The patient named below certifies that they have a physical or mental impairment that substantially limits one or more major life activities and that the service dog is necessary to mitigate the effects of that impairment. Provide a concise description of the impairment and the specific functional limitations relevant to the request for a service dog.

Responsibilities, Conditions, and Legal Acknowledgments

By signing this form the patient acknowledges and agrees to the following terms and conditions. Check each box to indicate understanding and acceptance.

I will maintain required vaccinations and provide records upon request.
I will maintain control of the service dog in all public settings and comply with public access rules.
I will comply with local licensing, registration, and leash laws applicable to the service dog.
I agree to indemnify and hold harmless the healthcare provider, facility, and staff from liability arising from the actions of the service dog, except where such liability arises from gross negligence or willful misconduct by the provider or facility.
I understand the provider/facility reserves the right to require removal of the service dog if it poses a direct threat or fails to remain under effective control.

Revocation: I understand that this authorization may be revoked by me in writing at any time and that the provider may terminate privileges for documented failure to maintain the conditions above. Grounds for immediate revocation include, but are not limited to, aggressive behavior by the dog that endangers others or repeated failure to control the animal.

HIPAA / Privacy and Release Authorization

I authorize the limited disclosure of medical information to verify the need for a service dog to housing providers, transportation carriers, and other entities as required to secure access privileges. Such disclosures will be limited to the minimal information necessary to confirm that the patient has a disability and that the service dog is needed to mitigate the disability. This authorization does not permit release of complete medical records unless separately authorized.

Authorization expires on:    I understand I may revoke this authorization in writing at any time, subject to actions already taken in reliance on this authorization.

Healthcare Provider Information (Attestation)

The following provider information is requested for contact and verification only. The provider's signature may be retained on clinic records. This form does not substitute for formal medical documentation when required by other entities.

Provider attestation: The listed provider has evaluated the patient and/or has documentation on file supporting the stated performance need of the service dog.

Additional Notes

Certification: I certify under penalty of perjury that the information provided in this Healthcare Service Dog Form is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of accommodations, revocation of privileges, or other remedies as allowed by law.

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