1Step 012Step 023Step 034Step 04 Full Name(Required) First Last I confirm I am at least 18 years old and not acting on behalf of anyone else.(Required) I confirm I am at least 18 years old and not acting on behalf of anyone else.(Required)Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Email(Required) Address(Required)Current State(Required)Please SelectNew YorkNew JerseyTherapeutic Emotional Support Animal(Required) Feline Canine Other If other was selected, please list your ESA.(Required)Gender & Breed(Required)Height & Weight(Required)Number of animals(Required)Have you experienced any significant changes in your mood in the past 6 months?(Required) Yes No Do you have feelings of sadness or depression?(Required) Yes No If yes, on a typical day, how long do your feelings of sadness or depression persist?(Required)Do you have feelings of anxiety?(Required) Yes No If yes, on a typical day, how long do your feelings of anxiety persist?(Required)Does your anxiety, sadness or depression interfere with any of your major life activities? *(Required) Yes No If yes, please describe what major life activities have been affected, and how.(Required)In your experience, does having an animal present help alleviate/ameliorate symptoms of your mental and/or emotional health issues?(Required) Yes No If you answered YES above, please describe how your animal helps alleviate symptoms of your mental or emotional health.(Required)General Medical History: Please list and describe any illness (psychological or physical) you have been diagnosed with and any chronic medical conditions you have.(Required)Prescription Drug Use: Please list the frequency and dosage of any drugs (OTC, prescription) taken in the last 6 months.(Required) Telehealth Consent(Required) I agree to the privacy policy.I understand that telemedicine is a means used for remote communication and exchange of information, particularly for delivering health care services via an electronic medium such as the internet with facilities for audio and video communication. I understand the laws that protect the privacy and confidentiality of medical information applies likewise in telemedicine. However, through telemedicine, the health care provider cannot control the patient's environment. I understand my right to withhold or withdraw my consent from the health care service provider or my physician. I understand that should I withhold or withdraw will not affect my relationship with the health care service provider or the doctor and my right to future care or treatment. I understand my responsibility in terms of the charges that I may incur for the medical services I use for myself, regardless of the insurance coverage. I understand that State laws require me to be within the state of New York, New Jersey and particularly in any of the following places in order for me to be treated through telemedicine: Hospitals and Hospice care Facilities for mental health care, including a psychiatric center, development center, institute, clinic, ward, institution or building Physician offices Schools and child daycare centers Adult care facility at home. Phone(Required)Email(Required) Product NameSelect Plans(Required) ESA Letter PSD Letter Combo (ESA Plus) Renewal Letter Renewal Letter – Combo This field is hidden when viewing the formSelect Plans ESA Letter PSD Letter Combo (ESA Plus) Priority Service Extra Documentation Renewal Letter Renewal Letter – Combo Total Credit Card Cardholder Name Card Details
