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Preventive Care Plan Agreement
Client Start Date: Agreement Fee:
Patient Client ID Yearly Fee:
The member named above, with whom this agreement is made, has purchased from Everglades Animal Hospital a Wellness Plan for the pet identified above. The plan consists of services specified below. The member agrees to pay provider the initial non-refundable membership fee and the annual or monthly installments stated above for the full term of this agreement, including renewal terms, subject to the cancellation provisions on then second page of this agreement. The plan services provided in this agreement are scheduled to be delivered within 12 month from the start date referenced above. Unused services in any plan year do not carry over to the next plan year. Listed services refresh upon renewal and are again available for each plan year.
TERMS AND CONDITIONS ON THE SECOND PAGE ARE PART OF THIS AGEEMENT
The following services are provided to :
- Examinations: - Vaccinations
- Unlimited Office Visits. - Rabies
- Canine Heartworm Test
- Fecal Flotation Exam (2)
- Deworming (Pyrantel only) (2)
Your choice of: (One per year)
1- Dental Prophylaxis includes: 2 - Major General Health Profile
- Pre-anesthetic Blood work -
- General Anesthesia - Chemistry Profile (Internal Organ function screen)
- Dental Cleaning (Scaling) - Electrolytes and Blood Gas Analysis
- Dental Polishing - Radiograph (3 views)
3 -Castration (Spay or Neuter)
- Pre-anesthetic Blood work
- Pre-medication/Induction (Propoflo)
- General Anesthesia (Sevoflurane)
YOUR VETERINARIAN WILL DETERMINE AND RECOMMEND WICH VACCINES ARE APPROPIATE FOR YOUR DOG TO RECEIVE.
Agreement and Authorization
By signing below, I/We as Members agree to the terms and conditions of this agreement and authorize
Member Name: ___________ _______________
Member signature: _______ _________Date:
Co-member Print Name:_________________________________
Co-Member Signature: _______________Date:
If signed by 2 Co-members, they are jointly and separately liable for all payments.
ADDITIONAL TERMS AND CONDITIONS ON NEXT PAGE
Wellness Plan-Terms and conditions
Your plan provides only the services listed on the previous page. It does not include any services not listed there, or any fees for medical care or services recommended as a result of illness, injury or transfer to a specialty or overnight hospital facility. Your plan provides services only for the pet named on the previous page. It may not be used for any other pet. Fees for services not included in this agreement must be paid in full at the time services are rendered.
3. Automatic Renewal: This agreement is effective on the start date shown in agreement information for an initial term of 12months (plan Year) and will automatically renew on the anniversary of the start date in each succeeding year for subsequent periods of one year until member or provider cancels this agreement as described in paragraph 7 below. Re-enrollment: After cancellation, member will have up to 30 days to reinstate their plan without paying a membership fee. Early Renewal: in certain situations, it may be recommended that a plan renew early if plan services have already been used. And are needed again, but are not available until after renewal. In order to make the needed services available sooner, Plans may be renewed up to 30 days early. when this occurs, member is responsible for the new renewal plan year just as if it had renewed automatically.
4. Payments: Monthy payment installments will only be billed directly to member's credit card. A reprocessing fee of $5.00 (five dollars) will be billed to member for insufficient funds, over limit status or any other reason a payment is unable to be processed based on the account information supplied by member. Member is responsible for immediately notifying provider of any changes in billing account information to avoid any payment reprocessing fees.
5. Cancellation: Either provider or member may cancel this agreement at any time, but there may be monies due upon cancellation. In the event cancellation results in monies due to member, such monies will be paid by provider within 2-4 weeks. Cancellation by member within 7 business days: if member cancels this agreement for any reason within 4 hospital working days of enrollment, the membership fee and any other fees paid are refundable less the undiscounted retail value of any and all service provided .Cancellation by member after 4 business days: if member cancels for any reason(including but not limited to death or loss of pet or transfer of ownership), whether before or after provider has rendered services, provider shall be entitled to retain the entire membership fee. Provider shall also be entitled to retain or recover from member all monthly installments that have previously been paid or become due, including the installment for the month in which cancellation occurs, regardless of the cancellation request date. In addition, upon cancellation prior to the end of the plan year, if the total undiscounted retail value of plan service provided exceeds the sum of monthly installments collected for that plan year, member shall be obligated to do one of the following:
6. (A). Immediately pay full retail fees for all services provided to the extent such fees exceed the total of monthly payments received by provider for the plan year; (OR)
(B). Immediately pay the total remaining Plan year monthly installments in full, if less than the amount described in (a); (OR)
(C). Continue making the monthly payments as they become due for the remaining term of the plan year then in effect. If Member has paid the full annual fee in advance, upon cancellation by member, provider will refund the greater of (a) one-twelfth of the annual fee times the number of full months remaining in the plan year or (b) the full annual fee minus the undiscounted retail value of all plan service that have been provided in the plan year. Cancellation by provider: provider reserves the right to cancel the plan at any time and for any reason. In the event provider chooses to cancel the plan for any reason except member's default. Provider will waive any future payments due under the plan and discharge Member's obligation under this agreement if full.
7. Plan Price and Services Change: The initial price of the plan is the price in effect at the hospital where the pet is enrolled. The price of any subsequent renewal plan is the price in effect at the hospital upon the renewal date. Provider reserves the right to adjust monthly fees, services and the terms and conditions of this agreement as of the date of any renewal of this agreement. Provider will give member notice of any such changes no less than 30 days prior to the date they are to become effective.
8. Exclusions: The following items and services are not included in this agreement: (A)Grooming Services and/or boarding, Medication not listed above, Lab. test not listed above, Nail trim,and Hazard waste fees,
(B) Services, including office visits and consultations rendered by specialists to whom the pet is referred by provider. (C) Services at any institution, clinic, or hospital other than
9. Default: In the event member fails to pay any monthly installments within 15 business days of its due date, provider has the option to immediately cancel this agreement, discontinue plan services and immediately charge full retail fees for all services provided up to that date. After 15 business day the member's account will be referred to a third party collection agency. Collection activity may negatively impact member's credit bureau information and is subject to additional collection fees. if provider permits member to restart a plan after cancellation under this section 9, a new membership fee will be required unless special arrangements are made between the member and provider and agreed to in advance.
10. Collection Cost: If the member fails to make any payment when due under this agreement, the member shall pay the provider's collection cost, whether or not a legal action is commenced. In the event of any legal procedure (including appeals or bankruptcies), the prevailing party shall be entitle to recover its cost, disbursements and reasonable attorney's fees as determined by the court.
11. Multiples Members Joint and Several Liability: If two or more members sign this agreement as members, they will be jointly liable and each of them will be separately liable, for all the amounts payables under this agreement. If two or more persons sign this agreement as members as used throught this agreement will include each and all of them.