Pet Wellness Clinics

Annual Pet Prime Membership


Client Information

First Name:  
Last Name:  
Email:  
Have you been to one of our locations before?:  
How did you hear about us?:  
Street Address:  
City:  
State:  
Zip:
Phone Number:  
Type:  


Patient Information

Pet Name:   
Sex:  
Has this pet been to one of our locations before?:
Spayed or Neutered?:  
Species:  
Breed:  
Color:  
Age/DOB:  


Plan Information


Payment Information

Credit Card Number:   
Expiration Date:   
CCV:   


I understand that I will be billed for the annual membership fee and first month’s payment today when I check out. I approve my credit card to be billed monthly for the additional 11 monthly payments. I understand that I will be sent home with no more than 6 months of preventative at any given time, each plan is a 12 month, non-cancellable policy, and fees are non-refundable. I understand that prescription preventatives and any medications are unable to be returned, and all services and products are only able to be received during the membership year. (For example: if you fail to pick up your second six months of preventative before the end of your membership year, you will lose that product.) Pet Wellness Clinics are not responsible for overdraft fees associated with my plan. If my payment is not made within 5 days of my normally scheduled payment date, my plan will be terminated and I will be responsible for paying for the unpaid services & products. Unpaid services & products are determined by invoicing used services & products at regular cost and applying credit for the plan’s monthly payments that have been made (credit of monthly payments does not include membership fee). I understand that if my pet has a lapse in heartworm prevention for more than 30 days, I am responsible for updating my pet’s heartworm test at my cost, prior to receiving additional preventatives.


Date:  

Leave this empty:

Signature Certificate
Document name: Annual Pet Prime Membership
Unique Document ID: 21fb2c6b48f4e9d76a859c690359f1df579fe0ae
TimestampAudit
February 23, 2019 2:04 pm EDTAnnual Pet Prime Membership Uploaded by Elizabeth Smart - info@petwellnessclinics.com IP 50.195.188.246
February 27, 2019 3:47 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 45.251.50.138
March 20, 2019 1:28 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 45.251.51.248
March 20, 2019 2:07 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 45.251.51.248
March 20, 2019 2:07 pm EDTPet Wellness Clinics - chet@thecaway.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 45.251.51.248
March 20, 2019 2:11 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 45.251.51.248
April 8, 2019 4:51 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 182.156.99.44
April 21, 2019 11:56 am EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 96.64.138.9
June 26, 2019 3:13 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 182.156.105.182
June 26, 2019 3:13 pm EDTPet Wellness Clinics - clientservices@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 182.156.105.182
June 26, 2019 4:24 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 182.156.105.182
June 26, 2019 4:24 pm EDTPet Wellness Clinics - clientservices@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 182.156.105.182