Online Medical Exam

Section 7: SOCIAL PHOBIAS

1.Do you have difficulty speaking in front of groups or a fear of talking to strangers in general?*

Yes
No

2.If you answered yes to the above question, please describe the difficulty as it relates to you below.

3.Does the fear in the previous question cause you to have debilitating anxiety?*

Yes
No

If you answered yes to the above question, please describe below the symptoms associated with your anxiety.

4. Are you afraid of embarrassing yourself in public or in front of others?*

Yes
No

If you answered yes to the above question, please explain below why you feel this way.

5. Has your fear of embarrassing yourself in public caused you to avoid your daily responsibilities such as work, school, or any other public events?*

Yes
No

If you answered yes above, please describe below what major life activities have been impacted by your social phobias? Examples include: Walking, talking, lifting, reading concentrating, communicating, sleeping, and/or writing)

6. Are you afraid of flying on a commercial airliner?*

Yes
No

7. Do you get anxious and worried if you fly?*

Yes
No

If you answered yes to the above question, please describe the nature of your anxiety and worry below.

8. Do you avoid flying when possible?*

Yes
No

9. In your past and/ or present life experiences, has had having an animal helped alleviate/ ameliorate your complaints, problems or issues, and is that the reason in which prompted you to submit this medical exam?*

Yes
No

If you answered YES above, please explain further in detail.

Choose a Plan:*

Compassion Plan - $199 (Covers 1 Pet Only)
Care Plan - $159 (Covers 1 Pet Only)
Travel Plan - $149 (Covers 1 Pet Only)

Additional Pets

Do you have or want more than 1 pet as an ESA? Get a discount of ONLY $99 for each additional pet!

Would you like a hard copy of your letter sent via USPS?*

ESA Letter via USPS Standard +$10.00
ESA Letter via USPS PRIORITY w/Tracking +$20.00
No Hard Copy

* We will email you an ESA PDF letter regardless of what option is selected. The Hardcopy of the ESA letter is printed on special 67lb weighted paper and should be used when traveling overseas.

ID Card Sample

ESA ID Card Mailed via USPS?*

1 ESA ID Card via USPS Standard
2 ESA ID Cards via USPS Standard
3 ESA ID Cards via USPS Standard
No ID Card

Pet Name*

Pet Breed

Please enter breed like this, "terrier" or "terrier/poodle" and leave out american or any other additional info like "american" or words "with" etc.

Pet Weight*

Pet Image*

Pet #2 Name*

Pet #2 Breed*

Pet #2 Weight*

Pet #2 Image

Pet #3 Name*

Pet #3 Breed*

Pet #3 Weight*

Pet #3 Image*

Optional Same Day Service

Same Day Rush Service

Do you want or need this approval process expedited to ensure that you get your approval letter within 24 hours if you are approved? Get your submission to the top for a rush fee of ONLY $49.95!

Total

$0.00

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Very Important: Make sure that the address and zip code entered below match with what the Credit Card you are using has on file. If it does not match, the payment will not get approved and you will have to start the entire process over from the beginning.

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Coupon

Required*

BY CHECKING THIS BOX AND UNDER THE PENALTY OF PERJURY, I ACKNOWLEDGE THAT I HAVE ANSWERED THE QUESTIONS ON THIS QUESTIONNAIRE HONEST AND TRUTHFUL.

*

BY CHECKING THIS BOX I UNDERSTAND THAT I AM GIVING MY CONSENT FOR THE DOGTOR TO SUBMIT THIS QUESTIONNAIRE TO AN INDEPENDENT LICENSED MEDICAL PROFESSIONAL IN THEDOGTOR’s REFERRAL NETWORK TO REVIEW AND EVALUATE THIS QUESTIONNAIRE.

*

BY CHECKING THIS BOX I UNDERSTAND IF I AM APPROVED FOR AN EMOTIONAL SUPPORT ANIMAL(s), I WILL NOT BE ENTITLED TO ANY REFUND AMOUNT FOR ANY REASON.

Attention: You must submit payment in order for this medical exam to be evaluated.

Online Exam Form

Step 1 of 7

Part I: Personal Information

Section 2: General and Mental Health

Section 3: General Medical History:

Section 4: Major Depression

Section 5: Generalized Anxiety & Panic Disorder

Section 6: Post Traumatic Stress Disorder

Section 7: SOCIAL PHOBIAS