DEL AMO HOSPITAL Service Animal Acknowledgement Form

Service Animal Acknowledgement Form
1. Responsibility for care of the service animal
I have been advised that the care for my service animal is my responsibility and must accompany me at all
times. I have been informed where I can toilet, exercise, and feed my service animal. I agree to follow the
hospital staff guidance to reduce the risk of infection control issues.
2. Leash Law
I understand that my service animal is required to be on a harness at all times.
3. Separation from my service animal
If it becomes necessary to separate me from my service animal the staff will make all reasonable efforts to help
facilitate the transfer of my service animal to the below designated person:
Name : _________________________________
Phone Number: _____________________
I understand that the above named person will have 24 hours to pick up the service animal. In the event, no
person is named, or the named person is unavailable after 3 tries over a 24hour time period, or the named
person does not pick up my service animal within 24 hours, then the animal will be referred to the SPCA. If I
am a voluntary patient, I will be given the option of continuing to receive treatment without having the service
animal on the premises.
4. Rabies Vaccine
I understand that I must provide proof of current rabies vaccination prior to admission if I am a voluntary patient
or within 24 hours of admission if I am an involuntary patient.
5. "Restricted Access" Areas
I understand that there are several restricted access areas in which my service animal will not be allowed.
Examples of these areas include Private Room Areas (PRA) for crisis intervention, ITU due to acuity of
patients, and any area in which transmission based isolation precautions are in place.
6. Procedures for Decisions Regarding Service Animals
In the event that a question or dispute arises about whether my service animal can accompany me in a
particular area of this facility, I can request a case-by-case decision be made.
I understand that Del Amo Hospital may also exclude or terminate the stay of my service animal if it acts in a
vicious, aggressive or threatening manner toward staff, patients, or visitors by unruly behavior such as barking,
snapping, biting, baring of teeth, growling, hissing, scratching, jumping on others and other extreme behaviors,
all of which are uncharacteristic of service animals.
7. Liability
I understand that I shall assume liability for the destruction of DAH property and any injury caused by actions of
the service animal and agrees to hold DAH harmless of all liability in such an event.
Patient Signature:________________________________________
Del Amo Hospital
Service Animal Acknowledgement Form
Patient Label:
Date: _________________