Patient Financing Program Application

Legal Practice / Business Name

DBA / Practice Name

Primary Contact

Title / Role

Email

Phone

Practice Address

Website

Medical Specialty / Services

Number of Locations

Years in Business

Approximate Monthly Patient Volume

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Typical Treatment / Service Price Range

Average Amount a Patient May Want to Finance

Currently Offer Patient Financing?

Primary Goal

What would you like a patient financing program to accomplish for your practice?

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I am authorized to submit this inquiry on behalf of the practice and agree to be contacted regarding qualification and onboarding.

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