Pet Wellness Clinics

New Client - New Patient - Annual Pet Prime Membership

Client Information

First Name:  
Last Name:  
How did you hear about us?:  
Street Address:  
Phone Number:  

Patient Information

Pet Name:   

Plan Information

Payment Information

Credit Card Number:   
Expiration Date:   

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
Signature Certificate
Document name: New Client - New Patient - Annual Pet Prime Membership
Unique Document ID: 292d568dc5eb69e18b67bb0164e54304fdc84c63
Timestamp Audit
February 23, 2019 2:04 pm EDTNew Client - New Patient - Annual Pet Prime Membership Uploaded by Elizabeth Smart - IP
February 27, 2019 3:47 pm EDTPet Wellness Clinics - added by Elizabeth Smart - as a CC'd Recipient Ip: