Patient Financing - Application Form

Patient Application

Please fill in your personal information below.








ex. (123) 555-5555




ex. 1234


ex. Grand Avenue


ex. 1234




Enter as A1A1A1. No spaces or dashes.


Help
Enter as 1000.99  NOT $1,000.99


Enter as 123-456-789


Enter as MM/DD/YYYY e.g. 07/23/1967 

Employment Information



Help
Enter as 1000.99  NOT $1,000.99


Ex: Disability

Help
Enter as 1000.99  NOT $1,000.99


           

As a financial intermediary between doctors and patients, Credit Medical Corporation: Works with patients to arrange loans, Enables doctors to offer patients financial alternatives, and links doctors and patients through our directory.