Seeing Eye Dogs Australia
A division of Vision Australia
17 Barrett Street
Kensington Vic 3031
Tel: (03) 9381 6400
Fax: (03) 9381 6464
ABN: 24 693 628 108
***This form must be completed by a registered
Medical Practitioner***
AUTHORISATION OF DISCLOSURE OF MEDICAL DETAILS
I, (Full Name: ……………………………………………………………….
Of (Address): ………………………………………………………………….
……………………………………………………………………………………
I have read or have had read to me and it’s been explained that the
contents and importance of the form below, requesting Medical Information
about me, in respect of training program/s I have applied for with Seeing
Eye Dogs Australia.
I am satisfied that I fully understand the content of the form and that the
medical information sought is a necessary part of my assessment for
suitability for the training for which I have applied and that all such
information will be kept in strict confidence.
Accordingly I hereby give my informed consent to provide Seeing Eye Dogs
Australia with the information sought as well as any subsequent detail if
required.
Signed: ………………….…………………………………………………..
Date: ………………………………………………………………………….
Name of Witness: ……………………………………….…………………
Signature of Witness: ……………………………………………………..
1
Information for Medical Practitioner
The person named above has applied to Seeing Eye Dogs Australia for
training. The training course can be demanding both physically and
emotionally. It is likely to involve a period of residence away from home
where new skills will be learned. In general there will be an expectation of
at least two walks of reasonable length, (at least thirty minutes) each day.
There is also a requirement that the individual assumes responsibility for
themselves and takes responsibility for the dog including such activities as
feeding and grooming, which require a degree of bending.
Before the application is progressed and in order to best serve the client the
organisation would be grateful for both your general and specific
comments.
Any information provided will be dealt with as strictly confidential
Completed forms should be sent directly to Seeing Eye Dogs Australia
Name of applicant being assessed:……………………………………………….
Date of Birth…………….
Height………………………
Weight………………………
Please comment on the following areas:

General fitness level:
2

Respiratory System:
Any shortness of breath or exercise limitations?

Circulatory System including heart conditions
Any risk to the person with increasing exercise?

Movement, (bones, joints, balance, any history of muscle disease /
weakness, paralysis)
Any limitations to movement?
3

Endocrine system
Notably diabetes, but any other condition requiring precautions?

Nervous system:
Any compromise to movement considered or pain receptors?

Mental Health
Any issues of personality stability or history of depression, anxiety?
4

Sensory Loss:
Hearing loss or other sensory loss?

Substance abuse / dependence:
Present status if history of misuse.

Additional Comments e.g. ability to learn:
5

In your opinion would this person’s current health status hinder them
from training with a Seeing Eye Dog?
Medical Practitioners Name: ……………………………………………………..
Registration Number:…………………………………………………………………..
Practice Name: ………………………………………………………………………….
Signature: …………………………………………………………………………..
Date: …………………………………………………………………………………..
Thank you for your co-operation
Seeing Eye Dogs Australia
A division of Vision Australia
6