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I recently had a patient present with her service dog. My patient suffered from Sjögren’s syndrome, severe allergies with a high risk of anaphylaxis, rheumatoid arthritis requiring immunosuppressants, and recurrent herpes zoster infection due to immunosuppression.
The dog alerted when she was suffering from anaphylaxis. Her service dog was a Shih Tzu, and, due to the dog’s severe arthritis, required a stroller. Thankfully, the patient called a few days prior to her appointment to discuss the need for the dog to accompany her to her exam.
How would you handle this? These situations can be tricky, and not knowing current guidelines can result in patient complaints and even fines.
There are four types of support animals: service, emotional support (ESA), psychiatric support (PSA), and therapy animals.
Service animals are trained to perform major life tasks to assist patients with physical or severe psychiatric impairments/disabilities.
For a patient to legally qualify to have a service animal, she must have a physical impairment or psychiatric disorder that substantially limits her ability to perform at least one major life activity without assistance. There are no limitations to the kinds of impairments or disabilities for a patient to qualify.
A physical impairment includes any medical disorder, condition, disfigurement, or loss affecting one of the body systems. The disorder may be neurological, musculoskeletal, respiratory, cardiovascular, reproductive, digestive, genitourinary, immune, circulatory, hemic, lymphatic, skin, and endocrine. It may also involve a special sense organ.
This does not include temporary impairments of short duration with little or no residual effects. Environmental conditions and alternative lifestyles are not protected. Patients must be prepared to confirm they are disabled and provide credible verbal evidence of what their service dog is trained to do.
Americans with Disabilities Act
The Americans with Disabilities Act (ADA), as amended by the ADA Amendments Act of 2008 (ADAAA), 42 U.S.C. 12101, prohibits discrimination based on a “disability” in several areas. Areas include state and local government services, public accommodation locations, employment, telecommunications, and transportation services.
According to this federal law, people are entitled to be accompanied by a service dog anywhere a non-disabled person might go, even if pets are not allowed. This entitlement also extends to the cabin of an aircraft without being charged a fee.
(For the record, on your next flight, the animal must be able to stay on the floor between the paying passenger’s knees and the seat in front of him. If the animal is too large or the plane is too crowded, the passenger may be required to crate the animal.)
The definition of “place of public accommodation” applies to optometric offices. This includes almost every type of business or establishment which serves the general public.
It also includes any commercial facility operated by a private entity whose operations fall within at least one of the following categories:
• Places of lodging such as a hotel or motel.
• Establishments serving food or drink such as a restaurant or bar.
• Places of exhibition or entertainment such as a movie theater, concert hall, or auditorium.
• Places of public gathering such as an auditorium or convention center.
• Sales or rental establishments such as a grocery, clothing, or hardware store.
• Service establishments such as a dry cleaner, bank, pharmacy, hair salon, or optometric office.
• Stations for public transportation such as an airline terminal or bus station.
• Places of public display or collection such as a museum or library.
• Places of recreation such as a local park or amusement park.
• Places of education including public and private schools.
• Social service center establishments such as a homeless shelter or substance abuse treatment centers.
• Places of exercise or recreation such as a tennis club, bowling alley, and a golf course.
Title III of the ADA does not apply to entities not open to the public, religious organizations, or places of worship.
Emotional support animal
An ESA is a pet that has been prescribed by a mental health professional, such as a licensed therapist, psychologist, or psychiatrist.
An ESA can also be prescribed through the internet from a video conference with a therapist, costing about $150.
The animal is part of a patient’s individual treatment program to minimize symptoms of the patient’s emotional or psychological disability.2
For a patient to legally qualify for an ESA, she must be considered emotionally disabled by a licensed mental health professional through a prescription letter.
All domesticated animals may qualify as an ESA, including mice, rabbits, birds, snakes, hedgehogs, rats, hamsters, guinea pigs, mini pigs, ferrets, and even small horses. An animal’s age is not relevant.
Specific task-training is not required because the animal’s presence addresses the symptoms associated with a patient's psychological or emotional disability. The animal must be manageable in public and not create a nuisance around the home.
A prescription for an ESA is most commonly done to allow the patient to fly commercial carriers with the animal in the cabin of an aircraft without being charged a pet fee, as well as qualify for no-pet housing without being charged a pet fee.
The Air Carrier Access Act 49 U.S.C. 41705, Dept. of Transportation 14 C.F.R. Part 382, Fair Housing Amendments Act of 1988 protects emotionally disabled people and their ESAs.
Psychiatric service animal
A PSA is a service dog for a person with a psychiatric impairment. These dogs are individually trained to mitigate their handlers’ psychiatric disability. The PSA’s function is not to provide emotional support but to perform tasks which enable their handler to function in ordinary ways.
This may include guidance during a dissociative episode, assisting a patient during a panic attack, or helping patients with post-traumatic stress disorder (PTSD) to function.
An animal that has been obedience trained to interact favorably with humans and other animals is a therapy animal. This animal’s purpose is to provide affection and comfort to patients in hospitals, retirement and nursing homes, hospices, and disaster areas. Therapy animals are not protected by federal law; they are privately owned.
Service animals are not required to wear identification such as a vest or special collar. These items are easily available, and an ESA may appear to be a service dog when wearing the service dog’s identification.
Support animal protocol
If a patient requests that an animal accompany her to a doctor’s visit, you cannot interrogate the patient about the animal.
You may ask only two questions:
“Is the dog a service animal required because of a disability?” and “What work or task has the dog been trained to perform?”1
Your staff are not allowed to request documentation for the dog or require the dog to demonstrate the task it performs for the patient. You and your staff should not ask for information about the patient’s disability.
A service dog must be controlled by the handler. You may notice a difference between the training of a service animal and an ESA because service animals require more training. Should the dog’s behavior become disruptive or threatening or beyond the handler’s control, your staff may request that the dog be removed from the office.
It is best for your practice to develop an office policy to address a patient’s request for an animal to accompany her on an office visit. While service animals must be allowed, you may choose to forbid emotional support animals.
Are you allergic to dogs? Allergies and fear of dogs are not valid reasons for denying a patient with a service animal or refusing to provide service.
Doctors with allergies may be able to accommodate a patient by keeping the animal in a separate space during the visit.
If a person in the office is at risk of a significant allergic reaction to a patient’s service animal, it is the doctor’s responsibility to find a way to accommodate the patient with the service animal and the person with the allergy.
1. US Department of Justice, Civil Rights Division, Disability Rights Section. Frequently asked questions about service animals and the ADA. Available at: https://www.ada.gov/regs2010/service_animal_qa.pdf. Accessed 11/29/18.
2. National Service Animal Registry. ESA registration and your rights. Available at: https://www.nsarco.com/esa-registration-and-your-legal-rights.html. Accessed 11/29/18.
3. J Brennan. Service animals and emotional support animals: Where are they allowed and under what conditions? ADA Network. Available at: https://adata.org/publication/service-animals-booklet. Accessed 11/29/18.