Patient Application

UniqueID_CMC
borrower_type
Language
IPAddress
Personal Information
This is a multiple page application. Please answer all questions as applicable.
Are you a Canadian Citizen or Permanent Resident?*
YesNo
Prefix
First Name
Last Name
Email
Home Phone
Primary number
Mobile Phone
Secondary number we can contact you at
Street or House Number
Street Name
Apartment or Unit Number
City
Province
Postal Code
Do you rent or own your home?
RentOwn
What is your MONTHLY mortgage or rent payment?
Social Insurance Number (SIN)
Birthdate
^(((0?[1-9]|1[012])/(0?[1-9]|1\d|2[0-8])|(0?[13456789]|1[012])/(29|30)|(0?[13578]|1[02])/31)/(19|[2-9]\d)\d{2}|0?2/29/((19|[2-9]\d)(0[48]|[2468][048]|[13579][26])|(([2468][048]|[3579][26])00)))$
Birthdate
Month / Day / Year
How did you hear about us?

Doctor or Clinic
Tell us about the doctor or clinic
Have you chosen a doctor or clinic already?
YesNo
1- Search for your Doctor or Clinic from our registered list
ClinicID
Can't find your doctor or clinic in the list above but have their contact information - Please enter it below.
2- Did you find your doctor or clinic in the dropdown above?
Yes, I have selected my Doctor above
No, I will enter my Doctor's information now
Doctor or Clinic Name
Clinic Telephone Number
Province
Clinic Address
City

Financial Information
Tell us about your financing requirements
Amount of Financing required
Enter to nearest dollar
Is the amount above exact or approximate
ExactApproximate
What is the term of the loan (months)
61224364860
If you have any other notes or comments you feel are relevant to this application, please enter them below.
Do you agree with our terms and conditions?
Yes, I Agree

Personal Information