Station Yard,

Station Road,
Trimley St Mary, IP11 0UB
Tel: 01394 271112
e-mail: whitworthvets@gmail.com
www.whitworthvets.co.uk

Pet Health Scheme About You

Membership application form Name

About your pet Address:___________________________________

__________________________________________
Is your pet a…. ____________________________________

 Small /medium / large / giant dog (Please delete as Postcode:

appropriate) Email:___________________________________
 Cat Phone: ____________________________________
 Rabbit
To be completed by veterinary practice
Your pet’s name :_________________________
Client ID: _________________
Your pet’s date of birth: _______________________
Scheme: _________________
Breed: ____________________________________ Staff name: ___________________
Signed: _______________ Date: ______________

Declaration and Signature Amount you are paying

I agree that the following monthly payments as detailed

I declare that the information I have given in this
below can be collected from my bank account on
application is true and complete. I accept the terms and
around the 10th of each month:
conditions issued by Whitworth Veterinary Practice Monthly payments of £ ______________(inc. VAT)
Ltd for the provision of the agreed routine healthcare
plan. I am 18 years old or over.
Signature________________________________

Date____________________________________
 General Plan Terms
and conditions:
Your Payment Plan is
administered by Whitworth Veterinary Practice Ltd, Station Yard,
Station Road, Trimley St Mary, IP11 0UB.
1. The cost, content and delivery of the goods and/or services paid
for by this Plan is agreed between you and Whitworth Veterinary
Practice Ltd.
2. Your Plan only remains in force if you pay your monthly
instalments, without default.
3. There is no insured benefit. THIS IS NOT AN INSURANCE
POLICY.
4. Pet Health Scheme only applies to the named pet on the
Registration Form and is not transferable between pets.
5. The scheme is payable by direct debit instalments at the prices
noted in the Registration Form. Payments will be managed by
'GoCardless’ on behalf of Whitworth Veterinary Practice Ltd. You will
be required to complete an online form, including a Direct Debit
mandate form. Once we have received confirmation that your
banking details are correct your Pet Health Scheme will be activated
and the contract between you and us will be formed.
We will provide you with notice of the activation date.
6. We may terminate this contract if you fail to make payments due
under it (in accordance with clause 5) or if, in our reasonable
opinion; you (and/or any person who brings the pet to us in relation
to the Services) are aggressive and/or abusive to any of our staff.
7. This contract is for a minimum of term of 12 months from the
date your direct debit is activated (the anniversary date) and, unless
you give written notice to terminate it shall continue for successive
12 month periods
8. You MUST be over 18 years of age.
9. If Whitworth Veterinary Practice Ltd is unable, because of a
default by you, to collect a payment they will inform you accordingly
and will attempt to collect the failed payment having given you
adequate notice in writing of the new payment date. If you default
on two successive payments, Whitworth Veterinary Practice Ltd will
inform you that your Plan has been subsequently cancelled.
10. The Plan is not transferable
11. Whitworth Veterinary Practice Ltd reserves the right to increase
the monthly payment shown on the registration form provided that
it gives you not less than one months’ notice of such increase. If you
do not agree with the increase you can terminate your membership
with immediate effect by notifying Whitworth Veterinary Practice in
writing within 2 weeks of receiving notice of the increase.
12: For dogs and cats, flea and worming treatment frequency will be
determined by the product. Dogs will be vaccinated against canine
distemper, canine hepatitis, parvovirus and 4 strains of leptospirosis.
Cats will be vaccinated against cat ‘flu’, feline parvovirus and feline
leukaemia virus.
13: For rabbits a single use dispenser of Reargurad™ will provide 10
weeks protection against fly-strike and the annual vaccination will
be against myxomatosis and rabbit haemorrhagic disease.
14: Dogs and cats are eligible to join the scheme at any point. If you
join before the primary vaccination course you are eligible to 10%
off the first vaccination and the second vaccination will be included
in the scheme. If you join during the primary vaccination course, you
will pay the full cost for the first vaccination and the second
vaccination will be included in the scheme. This scheme is for dogs,
cats and rabbits. All other species are excluded.
15: The services will be provided by us in accordance with the
normal standards of veterinary care. However, we can only provide
the services pursuant to appointments and it is your responsibility to
make sure that you and the pet named on the application form
make and attend appointments for services in accordance with the
Pet Health Scheme.
16: There may be instances where we are unable to provide the
services for reasons beyond our reasonable control. Such
circumstances include (but aren’t limited to) the absence of suitably
qualified veterinary staff and/or a shortage of necessary
vaccinations or drugs. Where we experience delays in the provision
of the Services to you for reasons beyond our control, we will do
what we reasonably can to minimise these delays and provide you
with another appointment. However, we will not be liable to you for
failure to deliver the Services in these circumstances.
17. By signing this form you are consenting to us keeping a record of
your personal data on our pet health scheme database and keeping
a paper copy of your original form. We will not keep these records
longer than necessary. You are also consenting to us sending you, by
e-mail a copy of our quarterly newsletter and news of other services
provided by Whitworth Veterinary Practice which may be of interest
to you.
Cancellation
You may terminate you membership of the Pet Health Scheme
during the initial term of one year if: (i) the pet named on the
registration form dies, (ii) you move house outside a 10 mile radius
of Whitworth Veterinary Practice Ltd (proof of change of address
will be required) , (iii) there is a material change in your
circumstances such as loss of employment or a significant reduction
in your income which Whitworth Veterinary Practice Ltds agrees in
its sole discretion and upon proof of such evidence of your change of
circumstances may reasonably require termination of your
membership.
If you cancel at any time other than on the anniversary date
(see Clause 7) after the initial term you will be required to pay us the
outstanding amount for any treatment received at the full list price.
You must give at least one month’s advance notice of your wish to
terminate your Pet Health Scheme after the initial term of one year
has expired. We will advise you of your last direct debit payment.
Upon termination of your membership in accordance with the terms
of this agreement you will no longer be liable to make any further
direct debit payments to Whitworth Veterinary Practice Ltd and will
no longer be eligible to receive any of the entitlements of the pet
health scheme.