- Step 1 of 2Patient InformationName *FirstMiddleLastDate of birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *We will email your invoice and a digital copy of your ESA letter.Phone *We will contact you soon to confirm your appointment.Preferred time for appointment *DateTimeESA Pet InformationEmotional Support Animal Name: *Breed/type *Color *Sex *Age *Spayed / Neutered? *YesNoWeightSignature *Clear SignatureI certify that each answer shown above is true and correct.NextHEALTH QUESTIONNAIRECheck if you have any of the following condition(s): (Please leave boxes blank if they do not apply to You)Conditions / Symptoms *ADD / ADHDAnxietyDepressionPhobiasUlcerSocial phobiaNervousnessCerebral palsyPost-Traumatic Stress DisorderBipolarAidsInsomniaOther health complications not listed:Initials *Disclosures and ConditionsPlease read carefully and initial each paragraph.Based on my belief and general information that I have obtained from different sources, which includes researching scientific literature about the established benefits and risks of using medicine(s) to treat my medical problems, I request the doctor to EVALUATE me for a possible prescription and responsible usage of medicine(s). *I agree to provide the physician with any and all copies of my MEDICAL RECORDS, if they exist, that document my medical conditions, as requested by the physician. *I agree to obtain medical FOLLOW-UP at my personal medical doctor’s office, or obtain a personal doctor if I have none now, and to return to this office for FOLLOW-UP, as recommended by the physician. I understand this is an obligation on my part for the continuity of care. Annual doctor visits are the minimum. *I have been assured that medical records relating to my care will be kept private and confidential and that no information will be released or printed, which would disclose my personal identity, unless required by law. *I do not have any active lawsuits or investigations against or involving this clinic, its physician(s), or its employees, nor am I a representative of any authorities who do. *SignatureClear SignatureFurthermore, the undersigned, my heirs, assigns, or anyone acting on my behalf, hold the physician, the principals, agents and employees, free and harmless of any liability resulting from the use of medicines or services from this clinic. This clinic, its staff and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. Should an approval be made for my medicinal prescription or services provided, I understand that terms and return dates will be specified. I understand that it is my responsibility to see a physician to assess the possible continuance of prescribed medicine(s) or provided service(s) beyond the terms of approval. I understand that the benefits and risks associated with the use of medicine(s) or service(s) may not be fully understood and that the use of medicine(s) or service(s) may involve risks that have not been identified. I certify that I have carefully read all the DISCLOSURES and CONDITIONS above with full understanding and agreement. I certify that all information I have provided in this ‘form’ is true and correct. I certify that all information verbally transmitted to the doctor is true and correct. I am seeking medication(s) or service(s) for my own, personal, medical use. I am aware that if any of my document(s) are lost or stolen medical document(s) replacement fee(s) may apply.NameSubmit
