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