Veterinary Service Animal Form
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1Service and Therapy Animal Form
Personal Information
Owner Name:
Pet Name:
Date:
Breed:
Colors:
Markings:
Sex:
Neutered?
DOB:
Age:
Owner Phone No.:
Cell No.:
Health Questions
Does pet have any symptoms?
Does pet have any injuries?
If pet is limping, which leg?
If pet is scratching, where?
Duration of symptoms:
Frequency of symptoms:
Current medication(s) used:
Dosage and Frequency:
Service/Therapy Evaluation
The pet has a calm and even temperament
The pet is not bothered by gentle touching or holding
The pet obeys basic commands
Is the service pet required because of a disability?
What is the pet training to do to mitigate the disability?
As the pet been trained by a certified service trainer?
Trainer:
Phone:
Location:
Does the pet have a certified training certificate?
I, _________________________, do hereby certify that the pet named above is healthy and suited for work
as a service or therapy animal.
Veterinarian Signature
Date
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Parent category: Medical