Name*

Date of Birth*

MM

DD

YYYY

Email*

Phone Number*

Gender:

Female
Male

Have you had any changes in your psychological and/or physical health in the past year?*

Yes
No

Please list the names of any prescription medications you have taken during the last 12 months or write NONE, if none.*

Have you experienced any major life events or traumatic events during the last 12 months?*

Yes
No

During the past 6 months have you been frequently worried about big and/or small life events?*

Yes
No

If you answered Yes, how frequently?

Do you have difficulties controlling your worries and anxiety?*

Yes
No

If you answered Yes, can you please describe what kind of events you worry about?

During the past 6 months have you been frequently sad, depressed for unknown reasons?*

Yes
No

If you answered Yes, how frequently?

On a typical day, how long do your feelings of sadness/depression persist?

Describe how you feel your Emotional Support Animal helps alleviate and/or relieves your mental/emotional symptoms.*

Please use this space to communicate anything else you would like your licensed mental health professional to be aware of.

Preferred Emotional Support Pet*

Dog
Cat

Number of animals*

Combo Plan*

Price: $99.00

EZ Automatic Annual Renewal

Automatic Annual Renewal Subscription

Most airlines and landlords require an ESA letter to be updated annually. Lock in your renewal rates this year. Combo plan clients are eligible for a discounted renewal, the discounted renewal rate for 2019 is $99. You can opt-in for the annual renewal subscription to ensure your ESA is covered. Annual Renewal Subscription will be automatically billed next year. You may CANCEL the subscription at any time before you complete the renewal questionnaire next year.

Add-ons

Extra Document for Airlines or Landlords
Priority Digital Delivery
Custom ID Card - ESADoctors Discounted Rate (Original Price $44)

Note: An ID card is an optional accessory that some ESA owners find helpful. An ID card or registration are not required by law.

Shipping Options*

Total

$0.00

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

*

I agree to renewal terms

*

I have read and agree with FAQs and Terms and Conditions

Annual Combo Plan Renewal

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