Diabetic Alert Dog Application

Diabetic Alert Dog Application
PLEASE DO NOT BEGIN THIS APPLICATION UNTIL YOU HAVE WATCHED THE VIDEO "HOW TO GET A DIABETIC ALERT DOG. THE STEP BY STEP PROCESS"

This video explains in great detail the process of getting a service dog from us, and you should be familiar with this process before applying. You can find the video on our website or our youtube channel. Thank you.
Did you watch the video on our website or youtube channel titled: "How To Get A Diabetic Alert Dog. The Step By Step Process"

Yes Not Yet
Patient Name *

Title First Name Middle Name Last Name
Preferred Name
Patient Gender *
Spouses Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Patient Birth Date *

Month Day Year
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Patient E-Mail *
Occupation
Are you a full-time student at a college?

Yes No
If yes, name of college
Marital Status:

Single Married Divorced Widowed Separated Domestic Partner
Please Describe Your Housing:

Apartment Single Story Home Fenced Yard Townhome Multi-Story Home Unfenced Yard Shared Greenspace Subdivision Rural
Do you have other dogs at home? If yes please please list name, age, breed, sex, and neutered or spayed.
How did you hear about our organization?
Please check your preferred method of contact:

E-MAIL CELL PHONE WORK PHONE HOME PHONE
Emergency Contact
Name
Relationship
Phone

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Medical History
Date you were diagnosed with type 1 diabetes. *

Month Day Year
Do you use tobacco in any form?

Yes No
If yes, please list type and frequency of use
Does anyone else in the household use tobacco in any form?

Yes No
Is anyone in your household allergic to dogs?

Yes No
Have you ever been hospitalized due to Diabetic Ketoacidosis?

Yes No
If yes, please describe number of times and length of visits.
Have you ever been hospitalized due to anything other than DKA or an injury?

Yes No
If yes, please describe number of times and length of visits.
Is anyone else (other than the applicant) in the household a diabetic?

Yes No
Are you currently under the care of a endocronologist?

Yes No
Date of last visit *

Month Day Year
Your most recent A1C
Do you have any allergies?

Yes No
If yes, please list
Have you ever owned a service dog?

Yes No
Do you currently own a service dog?

Yes No
If yes to either of the above please list the name of the organization/s you've worked with previously to obtain your SD.
Please describe your ideal service dog. You may include things such as breed, color, sex, and of course your expectations of how the dog will assist you.
I, the undersigned, certify that I (or my dependent) have filled out this form to the best of my ability. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my answer status.
Responsible Party Signature: ___________________________________ Date:______________

(The signature above will be physically signed when you visit the office.)
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Diabetic Alert Dog Application

Emergency Contact

Medical History