Northwest Diabetic
               Alert Canines
Thank you for considering adding a Northwest
Diabetic Alert Canine™ to your or a loved ones daily
life. We would like to learn more about you to ensure
that you are matched with the service canine that
will meet the appropriate temperament and skill.
Your full name:

Phone number we can contact you at:

Email address:

Complete Address:

Who will this Medical Alert Canine assist?
You
Family Member
Friend

Age of individual that canine will assist:


Do you have pets in the home?
Yes
No

If so, what type of pets and how many of each?

Are all the pets in your home spayed or neutered?
Yes, they all are
Yes, but some are not
No, they are not

If not all pets are spayed/neutered, please indicate how many are not:

Have you even owned a service dog?
Yes
No

If yes, whom did you obtain the dog from?:


Please, tell us about your lifestyle (work or trade, activity level, social interactions such as club meetings, etc):

Will your dog accompany you to outside of your home?
Yes
No

What modes of transportation do you typically use to commute?


Describe where you live. (Select all that applies)
Neighborhood
City
Country
Farm
House
Apartment
Townhouse
One Story
Two Story
Tri Story
Fenced Yard
Access to grassy or wooded area
Paths or sidewalks to walk your dog
Dog Friendly park nearby

How many adults live in your home?


Children?


Is anyone allergic to dogs in your home?
Yes
No

Have you discussed getting a Diabetic Alert Canine with your medical advisor?
Yes
No

How did you discover the Northwest Diabetic Alert Canines™ program?


Please add any comments/questions you have below: