Contents of the Template
This template includes:
- Patient Information Section: A place for the patient’s full name, contact information, and date of birth.
- Healthcare Professional Information Section: Space for the healthcare professional’s name, credentials, contact information, and license number.
- Clinical Assessment Section: A portion where the healthcare professional can detail the patient’s condition or disability that requires a service dog.
- Service Dog Information Section: Space to enter the service dog’s name, breed, and specific tasks the dog is trained to perform.
- Certification Statement Section: A statement in which the healthcare professional attests to the patient’s need for a service dog.
- Signature and Date Section: Fields for the healthcare professional’s signature and date of signing, to validate the note.
Why Use This Template
- Clarity and Ease of Use: This template is straightforward and simple to complete, which helps ensure that all necessary information is easily and clearly provided.
- Standardized Documentation: Using this template helps to maintain a consistent and professional format when certifying a patient’s need for a service dog.
- Time-Saving: This template is designed to save both the healthcare professional and patient time, streamlining the process and making it more efficient.
- Accessibility and Convenience: Available in Word and Google Docs formats, this template is easily accessible and can be completed digitally or printed as needed.
Ideal For
- Healthcare Professionals: Doctors, psychologists, psychiatrists, or other qualified professionals who are approached by patients needing a service dog for a disability or health condition.
- Patients with a Disability or Condition: Individuals who have a disability or condition that requires the assistance of a service dog and need a formal document to certify this need.
- Landlords and Housing Authorities: When a patient needs to provide proof of their need for a service dog in a housing situation.
- Airline and Transportation Companies: For when patients are traveling and need to provide proof of their service dog’s legitimacy.
