Medical Professional

Patient Information

ADL = Activities of Daily Living
Is this patient:
Yes Minimally No
Additional Info

Provider's Signature
PLEASE NOTE: All applicants are required to submit medical history forms from two treatment providers (psychiatrist, therapist, GP, neurologist, social worker, etc.) whom we then conduct phone consultations with. We customarily schedule these consultations by email. No personal client information will be transmitted over email. Also, please be aware that the applicants acceptance can not be processed until these consults are conducted, so we appreciate you responding in a timely manner.

Please type your name below as your electronic signature to certify that, to the best of your knowledge and belief, the information provided on this form is accurate. If you would rather sign the form by hand,  please print this form, sign it and submit it to: Diggity Dogs Service Dogs, 346 Conway St, Greenfield, MA 01301 or scan and email it to with a reference to the applicantʼs first name in the body of the email.