General Medical Waiver Form

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Your Details

First Name*

Last Name*

Email*

Phone number*

Ext.

Work Mobile Home

Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country*

Additional Information For Your Waiver Form(s)

1 X General Medical Waiver Form

THIS AGREEMENT is made between (type in your name)

Required

Characters Remaining: 500

Name of Animal

Required

Characters Remaining: 500

Sex

Required

Spayed/Neutered

Required

Species

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Characters Remaining: 500

Breed

Required

Characters Remaining: 500

Color

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Characters Remaining: 500

Approximate Age

Required

Characters Remaining: 500

Weight

Required

Characters Remaining: 500

Heartworm Status

Required

Characters Remaining: 500

Veterinarian Name

Optional

Characters Remaining: 500

Veterinarian Email Address

Optional

Characters Remaining: 500

Veterinarian Phone Number

Optional

Characters Remaining: 500

Estimated Expense:

Estimated Treatment Expense:

Optional

Characters Remaining: 500

Amount Owner will pay: (Up to $500, per animal, per calendar year)

Optional

Characters Remaining: 500

Amount requested CPP Pay (maximum $500, per animal, per calendar year)

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Characters Remaining: 500

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

Optional

Characters Remaining: 2000

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"

Printed Name

Required

Characters Remaining: 500

Signature

Required

Characters Remaining: 500

Date

Required

Street Address

Required

Characters Remaining: 500

City

Required

Characters Remaining: 500

State

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Characters Remaining: 500

Zip

Required

Characters Remaining: 500

"CPP"
The Community Pet Project, Inc.

Optional

Characters Remaining: 500

Position

Optional

Characters Remaining: 500

Date

Optional

By clicking I agree to the terms.

Your Details

Additional Information For Your Waiver Form(s)

1 X General Medical Waiver Form

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