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Emotional support animals (ESAs) may provide companionship and psychological support to individuals with mental health conditions, and dermatologists may encounter patients requesting ESA documentation or seeking to bring an animal into the clinical setting. These situations raise distinct ethical, legal, and practical considerations. Unlike service animals trained to perform disability-related tasks, ESAs do not have the same federal public-access protections. This paper provides a framework to help dermatologists distinguish service animals from ESAs, evaluate requests for ESA documentation, determine when additional evaluation is needed, and manage animal-access questions in clinical settings. A proportionate approach can support patients with disability-related needs while maintaining appropriate professional boundaries and consistent clinical practice.