Name Birthdate
Parent or guardian if minor
Home Phone Cell Phone
Emergency Contact Phone
Email
Address
City
State/Zip
Please tell us how you heard about us? i.e. friend (who?), internet, BgConnect
Have you ever owned a dog before? Yes No
Have you ever owned a service dog before? Yes No
To maintain optimal health of a service dog proper care and nutrition is required. Monthly costs, excluding veterinary care, typically are $80 to $100. Are you willing to accept this financial obligation? Yes No
Preventative veterinary and health care (i.e. heart worm preventative, flea and tick preventative, dental care, vaccinations, health exams, grooming ), excluding illness, injuries and emergency veterinary care, typically costs $500 annually. Are you willing to accept this financial obligation? Yes No
Other than your service dog are you planning on obtaining any other animals within the next year? Yes No
Please explain your reason(s) for wanting a Diabetic Alert Service Dog
Please tell us the type of home you have i.e. apartment, single/multi level, high rise
Please list names and ages of adults and children that live in the home
Do you have stairs? Yes No
Do you have an elevator? Yes No
Do you have yard? Yes No
If you have a yard is it fenced and secure? Yes No
Please describe the area that will be utilized for your dogs relief area (restroom)
Do you have a motor vehicle? Yes No
If you have a motor vehicle please provide make, model and year
Please describe public transportation that you use and how often, i.e. bus, subway, airline
Are you a student? Yes No
If yes please provide grade level, school address, principals name
Are you employed? Yes No
If yes please describe occupation and work environment i.e. office, factory, busy, noisy
Describe your lifestyle and activity level i.e. hobbies, sports, etc.
At what age were you diagnosed as a Diabetic?
What was the date of your last A1c?
What was the result of your last A1c?
Type of diabetes? Type 1 Type 2
Insulin dependent? Yes No
Insulin delivery method? Pump Injection
Do you have any of the following conditions? Deafness / Hearing loss Speech impairment Vision impairment Limited mobility Muscular weakness Memory loss Allergies Chronic pain Heightened emotions Depression Attention deficit disorder Hyper activity disorder Skin sensitivity Heat / cold sensitivity Balance or coordination problems Kidney disease Kidney dialysis Neuropathy Retinopathy Amputations Other condition - Please specify
Do you use any of the following? Glasses Prosthesis Leg brace Wrist brace Cane or crutch Walker Manual wheelchair Electric wheelchair Hearing aid
Are you or anyone in the household allergic to dogs? Yes No
If yes please describe who is alergic to dogs
Do you use tobacco products? Yes No
Does anyone in the household use tobacco products? Yes No
Please describe any dogs that live in the household or visit often. Include breed and age.
Please describe any other animals that live in the household or visit often
Please provide any additional information you feel is relevant
