Fillable Medical Recommendation for a Service Dog (Government of Nova Scotia)

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Medical Recommendation for a Service Dog (Government of Nova Scotia)

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Department of Justice Rev 28May2018 Page 1 of 4
Medical Recommendation for a Service Dog
This form is to be completed by a physician or nurse practitioner, conrming the requirement for a service dog.
Please ensure the appropriate sections of this form are completed. Do not leave blanks, as this form will not
be considered if it is not completed.
Please complete this application form and submit it with your application for a service dog team certicate.
Direct questions to: Department of Justice, Service Dog Program
Phone: 902-424-8805 or toll free 1-888-760-5577 (#6)
Email: servicedogs@novascotia.ca
Fax: 902-424-0700
Please complete parts 1, 2, and 4 and ask your doctor or nurse practitioner to complete part 3.
You will be responsible for any fees your doctor may charge for completing this form. If you are in receipt of
provincial health benets, please speak to your case manager regarding subsidy.
Part 1 Applicant/Patient Information
Name
Surname Legal Given Middle
Date of Birth
yyyy/mm/dd
Mailing Address
City/Town Province/Territory Postal Code
Part 2 Parent/Guardian Information (Secondary Handler for Service Dog, if applicable)
Name
Surname Legal Given Middle
Mailing Address
City/Town Province/Territory Postal Code
Part 3 Instructions to Physician and Medical Information
The attached list on page 3 and 4 provides guidelines with regards to aspects of disabilities that may warrant
the use of a service dog for daily living, and the types of tasks that a service dog may perform to assist a
person with a disability. The list of tasks is not exhaustive.
A service dog must be essential to an individual’s ability to function in day to day living and to be present in
all or most situations in order to lead as full and independent a life as possible.
Clear Form
NS
NS
Department of Justice Rev 28May2018 Page 2 of 4
To clarify, a service dog is NOT
• A therapy dog that the owner takes on visits to people in institutions or in their homes, providing others
with an opportunity to interact with a dog; or,
• An emotional support dog that provides only comfort and companionship to the dog owner.
It should be noted that, although a service dog can assist a disabled person with independent living, having
a service dog will also place a burden on the patient. Caring for a service dog may have a detrimental impact
on the health and wellbeing of the patient and/or the service dog.
Medical Information
Practitioner Information
Please check one.
q Nurse Practitioner (NP) q Examining Physician  Examination Date (yyyy/mm/dd)
Having reviewed the appropriate information about the patient’s condition and the guidelines supplied on
page 3 and 4 of this form, does the patient, in your opinion, have a disability that requires a fully trained
service dog to assist them in daily living? q Yes q No
What tasks or behaviours could the patient’s service dog perform in order to mitigate aspects of their
disability? Refer to the list under Service Dog Medical Form Guidelines.
1.
2.
3.
4.
5.
Physician/Nurse Practitioner Name
Legal Surname Legal First Name
Mailing Address
City/Town Province/Territory Postal Code
Telephone  Signature  Date
yyyy/mm/dd
May use rubber stamp for name address and telephone
 
NS
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signature
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Department of Justice Rev 28May2018 Page 3 of 4
Part 4 Patient’s Certication and Consent to Release Information
1. I certify that the information I have given to the physician or nurse practitioner completing this report is,
to the best of my knowledge, true and complete.
2. I understand that inaccurate, misleading, missing or false information may lead to denial or cancellation
of my service dog team certicate.
3. I authorize the release of this medical report and/or health information related to my application for
a Service Dog Team Certicate under the Service Dog Act to be disclosed to staff of the Service Dog
Program. I also authorize the tasks my service dog is to preform to mitigate aspects of my disability be
provided to the organization or person designated to perform service dog assessments.
Patient
Name Date (yyyy/mm/dd) Signature
This information will be used for the purpose of determining eligibility for a Service Dog Team Identication
Card as provided under the Service Dog Act. The personal information provided on this form is collected
under the authority of the Service Dog Act and managed in accordance with the Freedom of Information and
Protection of Privacy Act (FOIPOP). Should you have any questions, contact the Registrar, Service Dog Act.
Service Dog Medical Form Guidelines
The following list provides guidelines with regard to conditions that may warrant the use of a service dog
for daily living and the types of tasks that a service dog may perform to assist a person. The list of tasks
is not exhaustive.
Common Tasks Performed by Service Dogs
Hearing Hearing impairment to such a degree that the person requires a service dog to:
1. Alert handler to name being called
2. Alert handler to phone ring
3. Alert handler to oncoming cars
4. Alert handler to any potential dangers
5. Alert handler in the presence of others
6. Other auditory support tasks: please explain
Mobility Physical disability or mobility issues to such a degree that the person requires a service dog to:
7. Retrieve dropped items
8. Hold items
9. Carry items in a store or to another room
10. Place items on the counter at the cash register
11. Open/close doors
12. Fetch a cane, walker or other equipment
13. Assist handler to get up from a chair or the floor
14. Turn lights on and off
15. Assist with the transfer from wheelchair to chair
(as in restaurant)
16. Reach for items from a shelf or shopping cart
17. Answer a (cell) phone when it rings
18. Alert others in the event of an emergency
regarding handler
19. Alert handler to hazards such as steps, curbs,
potholes or other obstacles
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Department of Justice Rev 28May2018 Page 4 of 4
20. Fetch medications if needed
21. Assist with stairs
22. Assist with ambulation
23. Retrieve a purse, wallet, backpack or travel bag
24. Carry mail
25. Carry an item to another person
26. Pull or manoeuvre a wheelchair
27. Assist with shopping cart or basket
28. Push handicap or elevator buttons
29. Safely manoeuvre handler in a parking lot
30. Assist in a public restroom
31. Put an item away
32. Emergency body pull
33. Other mobility support tasks; please explain
Developmental Developmental disability such as Autism Spectrum Disorder or similar condition where,
under the supervision of a parent or guardian, a service dog can:
34. Calm child when agitated
35. Prevent the child from self-harming
36. Prevent the child from bolting
37. Facilitate social interactions for the child
38. Other development support tasks: please explain
Medical Conditions such as seizure disorders, diabetes, cardiac rhythm disturbances, etc. where a person
would benet from a service dog that can:
39. Alert handler to changes in medical condition,
such as low blood sugar, impending seizures or
cardiac rhythm disturbances
40. Fetch medication if needed
41. Fetch the phone so handler can call for help
42. Alert others to the need for assistance
43. Reassure handler during medical crisis
44. Watch over handler until help arrives
45. Assist handler in sitting or lying down in cases
of impending medical crisis
46. Assist handler in getting up from floor or chair
after medical crisis
47. Other medical alert or response tasks:
please explain
Psychological Psychological conditions such as Post-traumatic Stress Disorder or other psychological
conditions where the person requires a service dog to:
48. Provide tactile stimulations orientating handler
in the present
49. Assist with locating keys or telephone
50. Fetch medication if needed
51. Brace or lean against handler
52. Assist handler to leave a social situation, as with
panic attacks
53. Facilitate social interactions
54. Assist handler to to the presence of other person
55. Assist handler in creating a safe personal space
56. Assist handler in safely crossing street
57. Assist handler in safely manoeuvring across
parking lot
58. Assist handler to changes in mood or
mental status
59. Buffer handler in crowded place
60. Other psychological support tasks;
please explain
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Medical Recommendation for a Service Dog (Government of Nova Scotia)

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Completed 18 August 2021

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