Dog for epileptic First name* : Last name* : If this request is for a child, names and first names of the parents* : Email* : Phone / Mobile : Your street and number* : Postal code* : City / Town* : Country* : Date of birth* : National number* : Contact person* : Phone / Mobile of contact person : AVIQ number, if you have one* : Can you provide an emergency contact?* : And their phone number* : What tasks will be required of the dog? : Do you have other animals at home? : Yes No If yes, which ones? : Are you : Student Employee Self-employed Job seeker Other You live in a : Apartment without garden Apartment with garden House without garden House with garden Do you own a vehicle? : Yes No If not, how do you get around? : Do you have other animals at home? : Yes No If yes, which ones? : Are you willing to come twice a week to the Os'mose center for training? : Yes No How did you hear about Os'mose?* : How many seizures do you have on average per month? : Which doctor/neurologist and at which hospital are you followed? : Have you had surgery? If yes, what kind? : If yes, can you bring them if you have an appointment at the center? : What is your current (and past) medication? : What procedure should be followed in case of a seizure at our center? : Do you have medical tests (EEG, 24h EEG, etc.)? : Yes No What are your daily and regular routines? What might your dog be exposed to?* : Do you authorize Os'mose to collect your data? : Yes No Privacy policy : Yes, I agree with the privacy policy Fields marked with * are required Send my message
