Gulley Park Pets Wellness Plan Enrollment

Wellness Plan Monthly Cost

Outdoor Cat $35
Indoor Cat $27
Small Dog $41 (up to 24 lbs as an adult)
Medium Dog $44 (24.1-60 lbs as an adult)
Large Dog $46 (60.1-120 lbs as an adult)
Extra Large Dog $72 (120.1+ lbs as an adult)

Services Included for Indoor Cat:

Annual Core Vaccinations
Annual Wellness Exam
1 Additional Exam
12 - month supply of flea and tick prevention
10% off ALL products and services (excludes pet food & referral services)

Services Included for Outdoor Cat:

Annual Core Vaccinations
Annual Wellness Exam
1 Fecal Test
1 Felv/Fiv/HW Test
1 Additional Exam
12 - month supply of flea and tick prevention
10% off ALL products and services (excludes pet food & referral services)

Services Included for Canines:

Annual Core Vaccinations
Annual Wellness Exam
Heartworm/Ehrilchia Test
1 Fecal Test
1 Additional Exam
12 - month supply of flea, tick and heartworm prevention.
10% off ALL products and services (excludes pet food & referral severices)

Comprehensive Wellness Bloodwork

At the time of your wellness visit you can upgrade to a complete bloodwork panel to ensure even greater prevention and protection. Full wellness bloodwork is recommended for the early detection and treatment of medical conditions. We have different panels tailored to your pet’s age.

Full Wellness Bloodwork	Without Plan	With Plan
Total Wellness Blood Panel	$200.00	$170.00
Basic Wellness Blood Panel	$110.00	$93.50

*Get a routine spay/neuter or dental cleaning for an additional $25/month! (does not include in heat, pregnancy, cryptorchid and/or extractions)

**Add on Unlimited Exams for $15/month**

Name *

Prefix First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email

example@example.com

Do you have a pet enrolled in a premier pet care plan? *

Yes No

Pet Name *

Select Plan Type *

Are you enrolling multiple pets? *

Yes No

Would you like to add on Unlimited Exams for an additional $15 a month? *

Yes No

Would you like to add on a spay/neuter or dental cleaning for an additional $25 a month? *

Yes No

Pet Name

Select Plan Type

Pet Name

Select Plan Type

Pet Name

Select Plan Type

Pet Name

Select Plan Type

I, First Name Last Name , authorize Premier Vet Alliance Limited to charge my credit card/bank indicated below, the fees outlined above in this agreement on the Draft date* day of each month for payment of my Pet Care Plan .
*You can choose a preferred draft date from 1st-15th.

To protect client credit card information please only confirm the last 4 digits of the card you will be keeping on file for payments to process. A client service representative will call you to collect the card number by phone once we receive your enrollment form. *

Credit/Debit Card *

Visa Mastercard AMEX Discover

1.1 Upon signing this Agreement, the Veterinarian will collect a one-time membership fee in the amount of $35.00 and the first Monthly Fee. Thereafter, the Monthly Fee will automatically drafted pursuant to the Recurrent Payment Authorization signed by you.

1.2 You understand that you are responsible for ensuring that the payment has been withdrawn from your account. In the event that the payment has not been withdrawn, it is your responsibility to ensure that the appropriate funds are available the following month to cover the payment.

1.3 I understand that the authorization will remain in effect for a period of 12 months and will automatically renew for an additional 12 months unless it is cancelled in writing 60 days prior to the anniversary of this agreement, and agree to notify the veterinary clinic in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or Credit Card Company so long as the transactions correspond to the terms of this agreement.

Signature *

Clear

Wellness Plan Enrollment

The Pet Owner

Pet Details

Recurring Payment Authorization