Choose your Wellness Plan Wellness Sign Up Form Date* MM DD YYYY Name* First Last PhoneEmail* Horse nameWellness Plan Option (Choose One)* Silver Wellness Bronze Wellness Wellness Upgrade Options (Choose All That Apply)* CBC/Chem Package ACTH/Insulin Package No Upgrades Method of Payment*We accept all major credit cards, cash, check, CareCredit and Farm Plan. Please call the clinic with credit card numbers. TERMS AND CONDITIONS • Enrollment begins at the receipt of payment prior to first visit. There is no carry over to the following year. The enrollment period for the Silver and Bronze plans is open from 01/01/2018 through spring and late summer. A second enrollment period is open in the fall for the Silver plan only. • Payment and enrollment are required prior to appointment. We accept cash, checks, Farm Plan®, Care Credit® and all major credit cards for your prepayment convenience. • Please be sure to call in advance to schedule your Wellness appointments. There are no refunds or substitutions for any services offered in your selected level which are not utilized within the enrollment term. • If an enrolled horse is sold or dies while participating in the Wellness program, a prorated refund will be given or you may transfer the level to another horse (with a limit of one transfer per term). • Selected levels may not be changed during enrollment term, but may be changed the following enrollment year. • Any discounts offered through the Wellness program can only be applied to the enrolled horse. • Participants may split call fees, but additional unscheduled horses will not be seen during a Wellness appointment to ensure adequate time to evaluate your horse. • The following services are excluded from the Wellness program: √ Call fee √ Initial Booster Vaccines √ Additional services not specified Reminder - To receive the full benefit of your Wellness plan, please collect a fresh fecal sample to provide your veterinarian during your wellness appointment. The sample should be placed in a ziploc bag and should not be more than 24 hours old. If collected the night prior to your appointment, the sample should be refrigerated. Remember to label the ziploc bag with your name, your horse’s name and date collected.CommentsThis field is for validation purposes and should be left unchanged.