EmailMe Form - ESAUK - REGISTRATION

How Did You Find Us? *

Search Google

Search - Bing

Search - Yahoo

Facebook Page

Twitter

Instagram

Tumblr

Dog Groomers

Veterinarian

Friend

Newspaper

Doctor

Mental Health Org

Health Org

GP - Doctor

Council

Other

Emotional Support Animal Registration

Animal Type: *

Animal's First Name: *

Animal's Breed: *

Animal's Weight:

Animal's Height:

Animal's Length:

Animal's Chip Number:

Pet Passport?: *

Yes

No

Animal's Gender: *

Female

Male

Animal's DOB: *

MM / DD / YYYY

Upload Animal's Photo For ID Card:
(DO NOT SEND A CROPPED PHOTO - IT MUST BE IN FOCUS, BRIGHT LIGHT, CLOSE TO FACE) *

select photo and upload with form - make sure its like a passport photo of your animal

Flag Preference:

Does Your Animal Have Any Training?: *

None

Home Training

Professional Training

Other

If Trained What Level?

Upload Training Certificate

if your dog is professionally trained please upload the training certificate

Animal's Address: *

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

Animal's Instagram Address:

Name of Parent or Guardian if ESA Owner is under 16 years of age

First Last

Authorization of Parent or Guardian as the ESA Owner under 16

I Authorize this process for the person under 16 years of age under my care

ESA Handler

First Name: *

Last Name: *

Date of Birth: *

MM / DD / YYYY

Gender: *

Male

Female

Phone (cell preferred): *

Email *

Confirm

DUE TO LIMITED ACCESS TO MEDICAL PROFESSIONALS BECAUSE OF THE CORONAVIRUS A LETTER CAN BE SENT AS SOON AS YOU GET AN APPOINTMENT

Doctors/Mental Health Professional Information *

I will get later after Coronavirus over

I have a Letter from a Doctor or Mentals Health Professional

Can You Produce the Letter if Required? *

I will produce this letter after the Coronavirus

I can produce this letter if asked by ESA UK

Doctor's or Mentals Health Professional's Name

Address of Doctor or Mental Health Professional

Phone Number of Doctor or Mental Health Professional

Contact Email of Doctor or Mental Health Professional

if you do not have this type n/a

Date of Letter or Today's Date *

DD / MM / YYYY

Please review your information to make sure everything is as accurate as possible.
I hereby certify that information I have provided is accurate and correct to the best of my knowledge.

By inputting my signature, I confirm that to the best of knowledge, the information I have provided to ESAUK is accurate.

I also confirm that I understand my input information will be kept for ONLY 13 months & then deleted off the system except I agree to keep my name and email address after this period if I do not re-register.

I agree for the photo I have submitted to be used on Instagram with no name or location.

I understand that the behavior of animals cannot be guaranteed. I also understand that the behavior of domestic animals is sometimes unpredictable and that some domestic animals are capable of inflicting serious personal injury or death, as well as extensive property damage. Knowing the risks I agree to assume ALL those risks including, but not limited to; assuming the financial responsibility of any possible litigation arising from any incident in which I may be involved. I release, indemnify, and hold harmless ESAUK, ESAORGUK, and their Employees, Officers, Directors, Agents, or Contractors from any and all damages or personal injury. Any incident involving myself, the location, or those pets or actions of other participants and spectators will be my sole responsibility and I assume all financial liability and will also assume all and any financial costs associated with my actions.

I understand this is not to get my pet into places it is for my ongoing medical treatment.

NO REFUND as the documentation is printed and mailed to you by two outside companies & digital copies are also sent to you.

I also note that currently ESAs do not have the same rights as Service Animals & can be refused entry into any business. *

Clear

ESAUK - ONE YEAR *

ESA REGISTRATION

THIS SECTION HELPS ADJUST THIS FORM FOR ANY ISSUES

DEVICE USED *

PHONE

TABLET

PC/COMPUTER/LAPTOP

OTHER

DEVICE OS *

ANDROID

APPLE

WINDOWS

OTHER

IF PHONE USED

IF TABLET USED

IPAD

ANDROID

SURFACE

OTHER

BROWSER USED *

POSTAL / MAILING ADDRESS - CAPITALS PLEASE

FOR THE ESA CARD, CERTIFICATE & CERTIFICATION LETTER

NAME / TO *

STREET ADDRESS *

ADDRESS LINE 2 *

CITY *

COUNTY *

POSTCODE *

COUNTRY: