Lake Cross VH Wellness Plan Enrollment

Wellness Plan Enrollment

Veterinarian/Pet Owner Agreement
Wellness Plan Monthly Cost

*Feline Plan- $46

*Small Dog Plan- $57 (up to 25 lbs as an adult)

*Medium Dog Plan- $59 (25.1-50 lbs as an adult)

*Large Dog Plan- $61 (50.1-100 lbs as an adult)

*Extra Large Dog Plan- $71 (101.1-125 lbs as an adult)

* Giant Dog Plan $99 (125+ lbs as an adult)

Services Included for Felines:

Annual Wellness Exam
Annual Core Vaccinations
Adult Wellness Panel with Fecal
1 Additional Exam
12 Month Supply of Prevention
10% off ALL & Services (Exclusions Apply)

Services Included for Canines

Annual Wellness Exam
Annual Core Vaccinations
Adult Wellness Panel with Fecal and Heart Worm Test
1 Additional Exam with Bordetella Vaccine
12 - month supply of flea, tick and heartworm prevention.
10% off ALL Services (Exclusions Apply)
Savings of $112 and up!
The Pet Owner
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
Pet Details

The Pet Owner will pay per pet:
Pet Name *
Select Plan Type *
Are you enrolling multiple pets? *

Yes No
Pet Name
Select Plan Type
Pet Name
Select Plan Type
Pet Name
Select Plan Type
Pet Name
Select Plan Type
Recurring Payment Authorization
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 $50.00 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1.2 You understand that you are responsible for ensuring that the payment has been withdrawn from your account. In the event that the payment has not been withdrawn, it is your responsibility to ensure that the appropriate funds are available the following month to cover the payment.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
Should be Empty:

Wellness Plan Enrollment

Savings of $112 and up!

The Pet Owner

Pet Details

Recurring Payment Authorization