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NEW CARLISLE ANIMAL CLINIC PC PREVENTIVE HEALTH CARE PLAN PAYMENT AGREEMENT Date ____/____/____<?xml:namespace prefix = "o" ns = "urn:schemas-microsoft-com:office:office">
Client ______________________________ Pet _________________
Address ______________________________ City ______________State ____ Zip __________
Phone (_______)______________________ Alt phone (_______)____________________________
By signing below I agree to the following terms of a Preventive Health Care Plan (PHCP) for the above named animal under the administration of the New Carlisle Animal Clinic (NCAC) PC. The specific services, products and discounts are detailed on the attached form; substitutions are permitted only by approval of NCAC.
1. NCAC will bill the credit card listed below in the amount of $ ____ on or around the first of each month for 12 consecutive months for a total of $_____. The first billing will occur today and there will be an additional one-time $50 administration fee billed today as well. If I elect to renew the PHCP, and do so without any lapse in the monthly payment, this fee will be waived for each renewal, even if I elect to change the type of PHCP.
2. If the card payment is declined for any reason, NCAC will attempt to notify me at the above address/email/telephone number. If the payment situation is not rectified within two weeks, services, products, and discounts offered through the PHCP will be suspended, and all past due payments must be paid before the suspension will be lifted. In addition, there will be $5/month additional administration fee that must be paid before the suspension will be lifted. Should the payment be declined for two or more consecutive months, the balance of the entire year's payments will become due and will be turned over to collection for legal action.
3. I cannot cancel this obligation for any reason, including in the event that I no longer have the pet or if it should become deceased. If NCAC would opt to cancel my monthly obligation at my request (they are not obligated to do so), I will still owe the total of products and services used at the regular fee, adding back in other discounts that I have received, less the amount I have already paid not including the administration fee. My credit card will continue to be billed monthly until that amount has been paid.
4. There will be no refund for unused services.
5. All products and services purchased under the above named pet's account will be used only for this pet. They may be purchased only at the physical facility of NCAC; purchases online or at other facilities will not be reimbursed
6. I understand that this is not an insurance policy; the plan only provides the named products, services and discounts. Results of those treatments are not guaranteed nor are treatment of any complication covered.
7. Services including examinations are by appointment only, made at least 24 hours in advance in an available appointment time slot. Additional fees will be incurred for ?work in? or urgent care appointments.
Signed: _____________________________________ Date ____/_____/_____
Credit Card (MC, VISA, DIS, CARE) # ________________________________________________
Exp date ______/______ Sec code _______
Attach INITIALED PHCP