Medical/Mental Health Professional Form
This form must be completed by a licensed mental health professional (psychiatrist, psychologist, licensed clinical social
worker) including a medical doctor specically treating the passenger’s mental or emotional disability.
(Note: In completing this form, please refer to denitions below.)
Passenger name (print):
Animal type:
Animal breed:
Animal weight :
If the animal weighs more than 65 pounds, United will evaluate on a case-by-case basis whether the animal may safely travel on the specic ight(s).
Initial
I certify that the passenger has a mental or emotional disability* listed in the Diagnostic and
Statistical Manual of Mental Disorders.
I am a licensed medical/mental health professional currently treating the passenger's mental or
emotional disability.
The passenger is under my current and ongoing professional care.
I have prescribed treatment that requires the animal identied above to accompany the
passenger to accommodate his/her mental or emotional disability in the following manner:
(check one only):
outside of a kennel or carrier in the aircraft cabin during ight
inside of a kennel or carrier in the aircraft cabin during ight
at the passenger’s nal destination only (need not be transported in aircraft cabin)
Medical/mental health professional's license information:
Date and type of the license:
License number:
State or other jurisdiction in which license was issued:
Your name (print):
Signature:
Date:
Business phone contact:
Business email contact:
Definitions – As used on this form, the following terms have the meanings indicated:
*A mental or emotional disability means a mental impairment that, on a permanent or temporary basis, substantially limits one or more major life activities (see
denition below), and includes any mental or psychological disorder, such as an intellectual disability, organic brain syndrome, emotional or mental illness, and specic
learning disabilities, including but not limited to such conditions as emotional illness, drug addiction and alcoholism.
Major life activities means functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.
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