Diabetes assistance dog request form 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* : Country Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo (Democratic Rep.) Costa Rica Ivory Coast Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau North Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda Saint Barthélemy Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Date of birth* : National number* : Contact person* : Phone / Mobile of contact person : AVIQ number, if you have one : Are you diabetic? : Yes No Which diabetologist and where are you followed?* : Do you have a blood glucose monitoring device? : Yes No Are you satisfied with your device? : Yes No Can you send a copy of your glucose report for the last 15 days to pierre@os-mose.be? : Yes No Do you have any specific medical treatment? If yes, which one?* : 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 Are you willing to come to Os'mose twice a week for about a year? : Yes No If you have a sensor, please send glucose curves from the last few weeks* : If you are not satisfied with your sensor, can you explain why? : How did you hear about Os'mose?* : What tasks will be required of the dog? : What are your daily and regular routines? What might your dog be exposed to?* : Privacy policy : Yes, I agree with the privacy policy Fields marked with * are required Send my message
