Pet Wellness Clinics

Existing Client - New Patient - Annual Pet Prime Membership


Client Information

First Name:   
Last Name:   
Email:


Patient Information

Pet Name:  
Sex:  
Species:  
Breed:  
Color:  
Age/DOB:   


Plan Information


Payment Information

Credit Card Number:  
Expiration Date:  
CCV:  


I understand that I will be billed for the sign up 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, that each plan is a 12 month, non-cancellable policy, that fees are non-refundable, and that prescription preventatives and any medications are unable to be returned. Bridgeview Animal Hospital & 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 sign up 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.


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Pet Wellness Clinics https://www.petwellnessclinics.com
Signature Certificate
Document name: Existing Client - New Patient - Annual Pet Prime Membership
Unique Document ID: c6537c6890751e5c5f3bab74c6c1fe0b33c9f43b
Timestamp Audit
February 23, 2019 2:37 pm EDTExisting Client - New Patient - Annual Pet Prime Membership Uploaded by Elizabeth Smart - info@petwellnessclinics.com IP 45.251.50.138
February 23, 2019 3:00 pm EDTPet Wellness Clinics - chet@thecaway.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 103.77.2.16
February 27, 2019 3:48 pm EDTPet Wellness Clinics - info@petwellnessclinics.com added by Elizabeth Smart - info@petwellnessclinics.com as a CC'd Recipient Ip: 45.251.50.138