Patient Care Application

Patient Care Application
By selecting "Agree", you acknowledge that you have received, read, and agreed to the above documents.*

Agree

Patient Care Applicant

Applicant Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Care Application

Applicant Information
Date of Birth*

MonthDayYear
Date
Social Security Number*
Driver's License Number*
Photo of Driver's License

Browse Files

Cancelof

Patient Care Application

Applicant Information
Mortgage Holder or Landlord*
Mortgage / Rent Payment*
Years in Residence*
Do you rent or own your residence?*

RentOwn

Patient Care Application

Applicant Information
Employer name / If Self-Employed Name Business*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Annual Salary*
Years at Work*
Position*

Patient Care Application

Applicant Information
Other Income

List all other sources of income e.g. p/t work, social security, dividends, etc. (NOTICE: Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.) If you wish to rely on other income, you must provide us with the name, address, and phone numbers of the person(s) who will be making payments to you in the “Provider” section below. Use an additional sheet if necessary.
Do you want to include another source of income?*

YesNo
Other Income Amount
Source
Provider Name, Address and Phone Number

Patient Care Applicant

Co-Applicant Information
Do you want to include a Co-Applicant?*

YesNo
Co-Applicant - Name*

First NameLast Name
Co-Applicant - Email*
We will use this email to send your co-applicant a separate form to fill out.
Co-Applicant - Phone Number

Area CodePhone Number

Patient Care Applicant

Procedure Information
Physician Name*
Medical Practice Name*
Procedure Date*

MonthDayYear
Date
Procedure Cost*
Down Payment*
Amount Financed*
Preferred Term Length*
Preferred Monthly Payment

Patient Care Application

Disclosures And Signature
DISCLOSURES & NOTICES
- If you are married, you may apply for a separate account.
- Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
- By signing below, you acknowledge you have read and adhere with Article 22 (Privacy Policy) of the Revolving Charge Account Agreement.
- By signing below, you acknowledge you have read and provide authorization associated with Article 23 (Release of Information) of the Revolving Charge Account Agreement.
- By signing below, you authorize MedCred to conduct a credit review on behalf of the doctor named above, including obtaining a consumer report in connection with this application, as well as in connection with an update, renewal, extension of credit or collection of the account. Upon written request, you will be informed whether or not a consumer report was requested and, if such a report was requested, you will be told the name and address of the reporting agency that furnished the report.
- To learn about changes in the terms of the agreement accompanying this application, email us at support@medcred.co or call us at 213-267-1431‬.
CA RESIDENTS: After credit approval each applicant may be liable for all amounts of credit extended under this account to any joint application.

BEFORE SIGNING BELOW: The undersigned has read the disclosures that appear on this application and, the terms of which are incorporated by reference in and made a part of this application, and has received a copy of that agreement.
Date*

MonthDayYear
Enter Today's Date
Signature*

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Patient Care Application

Patient Care Applicant

Patient Care Application

Patient Care Application

Patient Care Application

Patient Care Application

Other Income

Patient Care Applicant

Patient Care Applicant

Patient Care Application