Serving Hillsborough County, Florida

COMMUNITY PET PROJECT

General Medical Waiver Form

THIS AGREEMENT is made between

("Owner) and The Community Pet Project, Inc., a Florida non-profit corporation ("CPP"), and relates to the following animal ("Animal"):

Approved Veterinarian: Treatment is available through the Humane Society of Tampa Bay (“HSTB”), or from another Approved Veterinarian of the Owner/Foster’s choice.

  • Indicate Preferred Veterinarian:
  • Humane Society of Tampa Bay or
  • Other Approved Veterinarian (name, email and phone are required):

Estimated Expense:

Estimated Treatment Expense:

(If not using HSTB, attach veterinarian’s estimate)

Amount Owner will pay:

(Up to $500, per animal, per calendar year)

Amount requested CPP Pay

(maximum $500, per animal, per calendar year)

Diagnosis and Treatment. Formal diagnosis of issue(s) or conditions(s) and treatment/medication required. (attach additional sheets if necessary):

CPP agrees to pay only for the above Treatment(s) performed by the Approved Veterinarian, not to exceed the Estimated Expense. Actual amount paid by CPP will be communicated via Confirmation Email to Owner and Approved Veterinarian. The veterinary billsfor Treatment listed above will be paid directly by CPP to the Approved Veterinarian. Owner will promptly remit copies of all invoices to CPP for payment and/or make advance arrangements for CPP to be invoiced directly.

Any treatments or medications not listed above will not be covered by CPP and will be the sole responsibility of the Owner.

Owner understands that CPP is not a medical provider and makes no representations or warranties, express or implied, regarding any medical care or treatment provided by the Approved Veterinarian. By his/her signature below, Owner authorizes the Approved Veterinarian to disclose any medical records or health care information related to diagnosis listed above to CPP upon request.

**All animals must be spayed or neutered to qualify for assistance. Extenuating circumstances will be discussed with the Owner and CPP’s medical advisors. CPP’s medical advisors will advise Owner of their decision via email, text or phone. CPP will assist in financial help for medical needs up to $500 per animal per calendar year.

"OWNER"

"CPP"
The Community Pet Project, Inc.