Heartworm Medical Waiver Form

Approved Veterinarian: Heartworm treatment is available through the Humane Society of Tampa Bay, or from another Approved Veterinarian of the Owners choice.

• Humane Society of Tampa Bay (“HSTB”): CPP will sponsor heartworm treatment for the animal. We ask
  that Owner pay as much of this cost as they can, and CPP will pay the remaining cost, up to 100% of the
  amount. This rate does not include the cost of the recommended antibiotic – the antibiotic cost is the
  responsibility of the Owner unless other arrangements have been made by the owner and CPP.
• Other Approved Veterinarian: CPP will pay Owner’s approved veterinarian an amount agreed upon
  between the Owner and CPP. It is recommended you confirm the cost prior to making a choice of HSTB
  vs. other Approved Veterinarian.
• Indicate Preferred Veterinarian:

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

Estimated Expense:

**CPP agrees to financially assist the client up to $500 per animal, per calendar year provided it is spayed or neutered. Extenuating circumstances will be discussed on a per client basis with the Owner and CPP’s medical advisors. CPP’s medical advisor’s decisions will be relayed to the Owner via email, text or phone call.

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. (Note: Owner does not need to submit invoices for treatment provided by the Humane Society of Tampa Bay.)

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.

"OWNER"

"CPP"
The Community Pet Project, Inc.