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Prequalification
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HIPAA Disclaimer
The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named below. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message.
1. Patients date of birth
*
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2. Which state do you intend to use the ESA letter in?
New York
California
Florida
Texas
We currently have doctors licensed in New York, California, Florida and Texas only. The ESA letters can only be used legally in the state where it is issued. You bear all legal risk if you use it in a different state. You can currently be from another state but intend to live or travel in NY CA, FL or TX.
3. Which type of pet do you have?
*
Dog
Cat
Other
I don't have one yet.
4. If other, mention which animal
5. What is the name of your pet?
6. What is its breed?
*
Type N/A or "Not Applicable" if not applicable to your pet.
7. What is its age?
8. What is the gender of your pet?
Male
Female
9. Have you ever been diagnosed with a mental health condition?
*
Yes
No
10. Have you experienced any major event in the past year that may have caused you any psychological distress?
*
Yes
No
11. Does your condition cause impairment that substantially limits one or more major life activities? (required for approval)
*
Yes
No, I do not qualify for an ESA and will exit the website.
The word “substantially” clearly goes beyond discomfort, daily stress, or normal fluctuations in mood. Major life activities” is to be broadly construed, and includes “physical, mental, and social activities and working.”
12. In the past few weeks, have you lost interest in things that you generally find interesting?
None
Always
Often
Sometimes
Rare
Never
13. In the past few weeks, how often have you felt more angry and agitated than before?
None
Always
Often
Sometimes
Rare
Never
14. In the past few weeks, do you feel like staying at home a lot and experience social anxiety?
None
Always
Often
Sometimes
Rare
Never
15. How often do you get anxious and worried?
None
Always
Often
Sometimes
Rare
Never
16. Please explain how you feel when you are stressed.
17. List any prescription medications you take.
18. How does your pet specifically alleviate the impairment(s) that substantially limits one or more major life activities.
19. How else does your pet offer emotional support to you?
20. Is your pet part of your on-going treatment for your condition(s)?
*
Yes
No
21. Do you want to fly with your pet in-cabin with Delta, United, or Alaska airlines?
No
Yes, I understand that I may be rejected by Delta, United, or Alaska airlines
Delta, United and Alaska airlines require on-going treatment which is not a service we provide to each patient. If you need to fly with these airlines exclusively, our letter may not work for you. If you need on-going treatment, please call us directly and we can refer you to the right place.
22. Do you accept all legal responsibility for the actions of your pet and indemnify us?
*
Yes
No
It is up to you to use the ESA letter responsibly. Large dogs and dangerous breeds carry risks that are the owners responsibility, with or without an ESA letter. You agree that you are liable and responsible for all of you and your pets actions and will not attempt to hold us liable or responsible.
23. Do you agree to our terms and conditions and privacy policies?
*
Yes
No
All terms and conditions and privacy policies can be found at the footer (bottom) of our website.
Email
This field is for validation purposes and should be left unchanged.