Wellness Bundle Enrollment Form

Wellness Bundle Enrollment Form
Owner Name*

First NameLast Name
Patient Name*

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date of Birth
Please indicate which Wellness Bundle you wish to enroll:*

Puppy Basic: Premium Wellness BundlePuppy Plus: Puppy Basic + Alter PackageAdult Basic: Premium Wellness BundleAdult Plus: Adult Basic + Phase 1 DentalSenior Basic: Adult Basic + Thyroid Testing + Urinalysis Testing + Senior ImagingSenior Plus: Senior Basic + Cardiac Testing + Phase 1 Dental
If you have additional questions about items that are included in the above Wellness Bundles, please visit our website: www.millsanimalhospital.com
Our Wellness Bundles include 12 months of Oral Heartworm, Flea and Tick Prevention. We can accomodate those who wish to receive an Injectable Heartworm Prevention that lasts for 12 months. This would be an upgraded feature. The cost would be an additional $59 with the down payment.

Please indicate below if you would wish to continue with Oral Heartworm Prevention or if you elect to upgrade to Injectable Prevention of Proheart12 and Bravecto for Flea and Tick Pevention.
Heartworm Prevention: Please select one*

Oral Heartworm, Flea and Tick + Parasite Prevention (Simperica Trio Included)UPGRADE: Injectable Heartworm Prevention (Proheart12 + Bravecto) ($59)
Does patient weigh over 100lbs?*
Please note, there will be an additional cost of $85 with the down payment for all Giant Breeds.
Wellness Bundle Terms and Conditions
Our Wellness Bundles provide the highest quality care for your pet at a discounted affordable price and spread the annual cost of your pet’s preventive care over 12 months, if so desired.

Purchaser has the option to pay in full or spread the cost over 12 monthly payments. If the purchaser chooses to pay for the plans in full, there will be an additonal 5% discount.

Bundles includes year long parasite prevention, planned preventative pet parenthood, state of the art anesthesia, monitoring, and optimal care packaging & procedures during your plan enrollment.

All items listed in the Bundles are completely optional, however, there will be no difference in price for items declined or missed. It is the owner's/purchaser's responsibility to ensure that all items/procedures are completed before the last day of the agreement.

Wellness Bundles are not pet insurance and does not cover sick or problem visits. We encourage you to add Trupanion pet insurance with your wellness bundle to provide 360 degree protection for your pet.

Additional Information:

Mills Animal Hospital Wellness Bundle agreements are good for one year and renew annually unless the client provides a request to cancel.

Plus (+) Bundles typically indicate a procedure that has been added, with this addition there are a few stipulations that we must follow:
- Surgical procedures cannot be scheduled within three months of starting/enrolling
Oral Heartworm, Flea and Tick Prevention will not be dispensed in quantities greater than 3 months.

Payment date changes are subject to a $15 administrative fee.

Failed/declined credit card transactions will be subject to a $15 administrative fee and 10% interest rate per month until paid.

If a client does not respond to requests for updated credit card information within 10 business days, the Wellness Bundle Agreement will be terminated and the account balance will be due immediately.

Any balance due over 90 days is subject to be turned over to collections.
Canceling a Wellness Bundle
A Wellness Bundle may be canceled for the following reasons:
- Relocation, re-homing of pet or death of pet.
Upon cancellation, the cost of services received, less installment payments made will be due immediately.

A 30 day notice is required prior to cancellation.
Required Documents

Please note that the intent for these documents are to expedite the process and minimize confusion while enrolling in our Wellness Bundles. If at any time during this process you feel uncomfortable, please give our office a call and we can assist with the below items. Please note that all of these documents will be required before the Wellness Bundle can be initiated.
Copy of Driver's License

Copy of Utility Bill in Owner's Name

(2) Credit Cards

Use sumbission boxes below to provide all of the above necessary information.
Please provide a photo of your Driver's License (Front)
Please provide a photo of your Driver's License (Back)
Please upload a copy of a Utility Bill

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Provide Picture of Primary Card (Front)
Provide Picture of Primary Card (Back)
Provide Picture of Secondary Card (Front)
Provide Picture of Secondary Card (Back)
Payment Options
Please select one of the following options:*

I elect to pay the Wellness Bundle in Full (including a 5% discount)I opt to allow Mills Animal Hospital to store my card and process monthly payments according to the Wellness Bundle that I have chosen.
Primary Credit Card Information*

Name on CardCard Number
Expiration DateSecurity Code
Second Credit Card Information*

Name on Credit CardCredit Card Number
Expiration DateSecurity Code
By signing below, I authorize Mills Animal Hospital to initiate the Wellness Bundle of my choosing and process payment as agreed upon in this document. *

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Wellness Bundle Enrollment Form

Wellness Bundle Terms and Conditions

Canceling a Wellness Bundle

Required Documents

Payment Options