Facility Name Facility Phone Number (###) ### #### Facility Website Address http:// Facility Address City/State/Zipcode Are visitors to your facility required to wear a mask? Do you require that visitors to your facility have the Covid 19 vaccination? Contact Name Contact Job Title Contact Email Address Contact Phone Number (###) ### #### Are there pets in the facility? Yes No Do other animals/pets visit the facility? Yes No If there are other pets in the facility, where will these pets be while PTO teams are on site? Where will visits take place in the facility? (i.e. patient rooms, common room, classroom, counselors office, school library, etc.) What will your staff do during PTO visits? (i.e. escort PTO team to patient rooms, supervise visits that take place in group setting, etc.) Describe your client population/residents. (i.e. 35 elderly memory care residents, 25 third grade students, etc.) What days and times of the week can you accommodate visits? (In addition to weekdays, please specifically let us know if you can accommodate visits on the weekend or in the evenings for our teams who work during the day.) How frequently would you like a visit? Do you need any of the records listed below? Check all that apply PTO Certificate Veterinarian Records PTO Insurance PTO Team Photo How do you see a pet therapy team benefiting your facility? Please be specific so that we can find a team that best meets your needs. Is there any additional information you would like to share with us? Thank you! We have received your information and will be contacting you soon. Facility Request FormIf you would like to request a regular community placement to your facility, please fill out the form below.
