Service Animal Documentation Physician's name:_________________________________ Physician's address:______________________________ City:_________________ State:___________ Zip:______________ Telephone:________________ Fax:_________________ E-mail:________________________ “The ADA defines a service animal as any guide dog, signal dog, or other animal individually trained to provide assistance to an individual with a disability. If they meet this definition, animals are considered service animals under the ADA regardless of whether they have been licensed or certified by a state or local government.” “If you have further questions about service animals or other requirements of the ADA, you may call the U.S. Department of Justice's toll-free ADA Information Line at 800-514-0301 (voice) or 800-514-0383 (TDD).” Search for Service Animal documents. Under the above legal definition, ____________, an animal belonging to my patient, ____________________________, is/are a service animal/animals. ______________________ has a known diagnosis of ________________ _______________________ provides the following service or services: (name of pet) (check all that apply) ______ Assists a vision impaired person. ______ Alerts a person with hearing impairment to sounds. ______ Pulls wheelchairs or carries and picks up things for a person with mobility impairment or impairments. ______ Assists a person with mobility impairments with balance. ______ Is a seizure alert animal. _______________ alerts _______________________ and directs her/him to bed or to the floor when ________________________ senses a seizure aura. The aforementioned disorder/disorders limits ______________________ restricting her/him in employment and activities of daily living to the full extent to which a “normal” person can or may participate. Microchip number is: __________________ Color: _______________________ Breed: _______________________ Spayed or neutered:____________________ Date of spaying or neutering:_________________________ Physician Name:____________________________________________________ (Print please ) Physician Signature:________________________________________________ Date:___________________________ (month/day/year)

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