Sample ESA Letter for Health Care Professional

SAMPLE LANGUAGE FOR HEALTH CARE PROFESSIONAL FOR
REQUEST FOR REASONABLE ACCOMMODATION
FOR SERVICE DOG OR EMOTIONAL SUPPORT ANIMAL

(THIS SHOULD BE ON THE HEALTH CARE PROFESSIONAL’S LETTERHEAD)

I,  [Name of health care professional] ________________________________ , have examined and evaluated [Patient name]_____________________________________. I am familiar with his/her medical history and with the functional limitations imposed by his/her disability.

I have concluded that she/he requires a Service Dog [or Emotional Support Animal].

[Patient name] has certain limitations which affect his/her activities of daily living. To assist in alleviating these difficulties, and to enhance his/her ability to live independently, I am prescribing a service dog [or Emotional Support Animal] that will assist in coping with his/her disability. Therefore his/her request for reasonable accommodation should be granted.

Dated: __________________      ______________________________________________                                                         [Signature and License number of health care professional]