Membership Cancellation Request

Name Name First Last
Email
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Pet(s) Covered by Membership
Pet(s) Covered by Membership
Reason for Cancellation

Reason for Cancellation Death of Pet (Please see pro-rated refund eligibility below) Financial Reasons Relocation Other Other
Cancellation Request Details:
I, the undersigned, hereby request to cancel my membership under the Vancouver Pet Urgent Care Membership Program. I understand that my membership benefits will end as of the date of cancellation, and I acknowledge the terms and conditions outlined in the Membership Agreement.
Date of Pet's Death (If Applicable) Date of Pet's Death (If Applicable) / MM / DD YYYY
Pro-rated Refund Request (If Applicable:

Pro-rated Refund Request (If Applicable: Yes, I am requesting a pro-rated refund. My pet passed away within the last 30 days of the membership and I am submitting a pet death certificate.
Pet Death Certificate
All pro-rated refund requests based on pet death will require a pet death certificate sent to info@vancouverpeturgentcare.com.
Preferred Payment Cancellation Method:

Preferred Payment Cancellation Method: Refund to Original Payment Method (If applicable) Credit to account
Acknowledgment and Signature
I acknowledge that the Clinic will process my cancellation request and that I have read and understood the terms and conditions of cancellation as outlined in the Membership Agreement. I also acknowledge that this request is being made in writing, as per the membership terms.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY