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Name
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First
Last
Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
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Email
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Pet Information
Pet Name
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Plan Type
Please Select
Canine Basic Plan
Canine Optimum Plan
Feline Basic Plan
Feline Optimum Plan
Puppy Basic Plan
Puppy Optimum Plan
Kitten Basic Plan
Kitten Optimum Plan
To review Wellness Plan options, click here.
Upon signing this Agreement, Four Corners Veterinary Clinic will collect a one-time membership fee in the amount of $45.00 and the first Monthly Fee outlined in this Agreement. Thereafter, you authorize Four Corners Veterinary Clinic to charge your credit card the fees outlined on this Agreement on the specified day of each month for payment of your Wellness Plan.*
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I understand
You understand that the authorization will remain in effect for a term of 12 months and will automatically renew for an additional 12 months unless it is cancelled in writing 30 days prior to the anniversary of this agreement. The services and products included in this Agreement must be used during the current term of this Agreement. Any unused services and products will not roll over to a renewal term.*
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I understand
In the event you cancel your plan outside of the terms of this agreement, you understand that you are responsible for payment of services used on your plan. Four Corners Veterinary Clinic will collect an early cancellation fee in the amount of $45.00, in addition to any balance owed. There are no refunds for unused services.*
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I understand
You certify that you are an authorized user of this credit card and will not dispute these scheduled transactions with your bank or Credit Card Company so long as the transactions correspond to the terms of this Agreement.*
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I understand
You understand that you are responsible for ensuring the payment has been withdrawn from your account. In the event that the payment has not been withdrawn, it is your responsibility to ensure that the appropriate funds are available.*
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I understand
In the event you have accrued a past due balance, we will automatically attempt to process your payment until it is successful. You understand that services will not be provided until the plan payments are made current.
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I understand
For a Wellness Plan included procedure, a refundable fee of $300.00 is required at the time of scheduling. In the event of a no show, the fee will be charged to your account. Wellness Plan clients will be charged a fee for Urgent Same Day exams. This fee will cover the difference in cost between our normal and urgent exams prices.
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I understand
I have read the wellness plans terms and conditions.
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I understand
Terms and Conditions here
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