Roker Park Veterinary Centre

Your Details

Title

First Name

Last Name

Phone Number

Email Address

Address

Street

Address Line 2

Address Line 3

City

Postcode

Country

The Pet lives at the same address

YesNo

Pet's Address

Practice Plan

Your Pet's Details

Name

Birthdate

Can be approximate if you don't know the exact date.

Species

Breed

Gender

Approximate Weight in Kg's

Neutered

YesNoI don't know

Microchipped

YesNoI don't know

Choose your Health Care Plan

The Health Care Plan most suited to your pet:

Plan Start Date

This is the date of the first Direct Debit payment. Your plan will not start until this date.

Do you need to sign up another Pet to a Plan?

Please choose the click "Add another pet" on the bottom right corner if so,

or click next otherwise.

Your Bank details

This is the account to pay the monthly Direct Debit for your pets health plan.

Account Name

Account Number

Sort Code

The Direct Debit Guarantee
• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
• If there are any changes to the amount, date or frequency of your Direct Debit Merlin Simple Payment Solutions Ltd Re Roker Park Veterinary Centre will notify you 7 working days in advance of your account being debited or as otherwise agreed. If you request Merlin Simple Payment Solutions Ltd Re Roker Park Veterinary Centre to collect a payment, confirmation of the amount and date will be given to you at the time of the request
• If an error is made in the payment of your Direct Debit, by Merlin Simple Payment Solutions Ltd Re: Roker Park Veterinary Centre or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society – If you receive a refund you are not entitled to, you must pay it back when Merlin Simple Payment Solutions Ltd Re Roker Park Veterinary Centre asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us at office@merinsps.co.uk

Confirmation

I understand that this is NOT an insurance policy

Yes

I confirm that I am currently a registered client of this veterinary practice

Yes

I am afraid that we are not currently registering any new clients at this time. If you are not a currently registered and active client, then we cannot accept you into the Pawsitively Purrfect Club. Apologies, but please check back at a later time.

I read the Terms and Conditions of the agreement

Yes

I am the account holder & the only person required to authorise Direct Debit payments on this account

Yes

Terms and Conditions

Merlin Simple Payment Solutions Ltd Privacy Policy

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