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 have read and understand the following:

  • I will be billed for the 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 for the initial benefit year.
  • This plan will AUTOMATICALLY RENEW in 12-month benefit year increments and I approve my credit card to be billed monthly for all of the additional monthly payments until I terminate my plan at the end of a benefit year.
  • I will be sent home with no more than 6 months of preventative at any given time (with the exception of Proheart 12).
  • This plan is a 12-month benefit year, that is non-transferrable, non-cancellable and that all fees are non-refundable.
  • Prescription preventatives and all medications are unable to be returned.
  • All services and products are only able to be received during the membership benefit year (For example: if you fail to pick up your second six months of preventatives before the end of your benefit year, you will lose that product)
  • Pet Wellness Clinics is not responsible for overdraft fees associated with my plan.
  • If payment is not made within 5 days of the regularly scheduled payment date, the plan will be terminated.
  • If the plan is terminated or cancelled for ANY reason (this includes, but is not limited to: pet is rehomed, pet passes away, pet is lost, etc.) during the benefit year, I am responsible for paying for all the services and products that have already been used in the plan during the benefit year.
    • The cost of all services & products already used in the plan 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 sign-up fee)
  • 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:  

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Signature Certificate
Document name: Annual Pet Prime Membership
lock iconUnique Document ID: 704a51dfd6998cfc5e6fac8c9492d5b677f8ccc7
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
January 3, 2020 2:49 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 50.195.188.246
January 3, 2020 2:49 pm EDTPet Wellness Clinics - clientservices@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 50.195.188.246
January 15, 2020 10:24 am EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 50.195.188.246
January 15, 2020 10:24 am EDTPet Wellness Clinics - clientservices@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 50.195.188.246