Get a Loan for Medical Services

Get a Loan for Medical Services
HOW MUCH WOULD YOU LIKE TO BORROW?
Loan Amount*
What service is this loan for?*
PERSONAL INFORMATION
First Name*
Last Name*
Suffix
Email*
Primary Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Home - Street Address*
City*
State*
Zip Code*
Occupancy Type*
Monthly Mortgage / Rent*
Date of Birth*

MonthDayYear
SSN*
Personal Reference Name
Personal Reference Phone Number*
Format: (000) 000-0000.
YesNo
YesNo
EMPLOYMENT INFORMATION
Employment Type*
Current Employer*
Current Employer Work Phone Number*
Format: (000) 000-0000.
Job Title*
Time at Current Employer (Years)
Gross Salary (Monthly)*
Other Income (Monthly)
YesNo
YesNo
When was your last pay date?*

MonthDayYear
When was your next pay date?*

MonthDayYear
By checking this box, I hereby authorize Sundance Medical Financing, LLC to verify my income and employment, which will include contacting my employer if applicable.
FINANCIAL INFORMATION
Bank Name*
Type of Account*
Account Number*
Bank Routing Number*
YesNo
Account Holder's Full Name*
Street Address*
City*
State*
Zip Code*
YesNo
What day of the month would you prefer to make payments?*
Yes (after you apply, an email will be sent to your co-signer)No
Co-Signer's First Name*
Co-Signer's Last Name*
Co-Signer's Email (must belong to co-signer)*
example@example.com
By checking this box and clicking “Submit Application” I understand and agree that I am providing written consent under the Fair Credit Reporting Act for Sundance Medical Financing, LLC ("SMF") to obtain, use, and share information from my personal credit profile or other information from one or more consumer reporting agencies in order to determine your qualification for financing and conduct anti-fraud security checks. I authorize SMF to obtain my consumer report and related information about me from one or more consumer reporting agencies. I further authorize and consent to SMF obtaining an updated consumer report and related information 30-60 days prior to the date of my anticipated medical procedure to determine if there have been any material changes in my personal credit history. I understand that any changes that impact my creditworthiness might require SMF to provide me with an alternative loan offer on different terms. You may use my consumer report for any legal purpose, including authenticating my identity, making decisions related to my loan, sending follow-up SMF loan offers, and servicing or collecting any SMF loan that I receive. I also authorize SMF to verify information in my application, and I agree that SMF may contact third parties to verify any such information.
By checking this box and clicking “Submit Application” I would like to receive marketing calls and/or text messages utilizing prerecorded messages and/or an automatic dialing system from SMF, its agents, and affiliates that provide reminders, notices, and special offers at the phone number(s) provided. Your consent is not required as a condition of obtaining credit or obtaining services from SMF. You may revoke your consent by email or by other reasonable means.
By checking this box and clicking "Submit Application" I agree that I have read, understood, and consent to Sundance Medical Financing, LLC's ("SMF") Privacy Policy, Terms of Service, and Electronic Communications.
Date

MonthDayYear
Should be Empty:

Get a Loan for Medical Services

HOW MUCH WOULD YOU LIKE TO BORROW?

PERSONAL INFORMATION

EMPLOYMENT INFORMATION

FINANCIAL INFORMATION