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]