Enrollment Agreement and Questionaire

Enrollment Agreement and Questionaire
Thank you for your interest in enrolling with Credit Technologies, Finance Your Care, or Chiro Credit . Please complete the information below so we can get your Practice set up, and we can identify the lenders in our portfolio that will be the best fit for your Practice. If you have any questions or concerns, please call (844) 995-4657.
Practice Information:
What is the legal name of your Practice*
Make sure you include (LLC, PA, Inc)
What is your Practice specialty (i.e. Chiropractic, Plastic Surgery, etc.)*
What is the Doctor's name

First NameLast Name
What is the Owner's name (if different)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
What is the Practice email*
Who is the contact person we should call or email?*

First NameLast Name
Contact person's phone number if different than above
Please enter a valid phone number.
Contact person's email if different than above
example@example.com
What is your Practice website?*
If you want your logo on the application page we set up for your Practice, please upload an image of your logo (exp. JPEG)

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Your Current Financing Options

The next section ask about your gross sales, current lending options, and average loan volume. This is asked so we can match your current set up and needs, with lenders in our portfolio.
What are your Practice Gross Annual Sales*
How many loans do you close every month?*
What is your average loan amount?*
Please list the Patient Financing companies you are currently enrolled with in the order in which you typically use them (i.e. Care Credit, Cherry, United). Make sure you include all of your options here even if you haven't used the company for a while. If you are not offering Patient Financing at this time, just enter "None".*
Programs you are interested in learning about:

Finance Your Care has access to a very large network of lenders. However, we do not want to waste your time enrolling with lender programs you are not likely to use. Please answer the following so we can identify the best programs for your Practice.
What best describes your preferred involvement with the patient financing process?*
How important is it for you to offer 0% promotional rates? *
How important is it for the funds to be paid directly to your Practice? *
Our Lender Options and Fees:

Below is a basic outline of our lender programs. Please make a selection in each area.
Prime Lenders (685 and up)

Our Prime lender options would be comparable to a patient financing company such as Care Credit. However, while most patient financing companies require a 685 credit score at this level, our Lenders will approve people with credit scores down to 640. The average fee to your Practice with these lenders will be between 0% and 7.5%.
Do you want to enroll with our prime level lenders? *
Off-Prime Lenders (Down to 620)

Our off-prime lender options will approve people with credit scores down to 620. The average fee to your Practice with these lenders will be between 7% and 12%.
Do you want to enroll with our "off-prime" lenders? *
Fair Credit Lenders (Down to 580):

Our Fair credit lender options will approve people with credit scores down to 580. The average fee to your Practice with these lenders will be between 15% and 22%.
Do you want to enroll with our "fair credit" level lenders? *
Poor Credit Lenders (down to 500)

Our Poor credit lender options will approve people with credit scores down to 500. The average fee to your Practice with these lenders will be between 22% and 35%.
Do you want to enroll with our "poor credit" level lenders? *
Bad / No Credit Lenders (Billing Plan):

For people with very bad or no credit, we have a lender that offers a payment plan that only pays your Practice as payments are collected. However, as long as the Borrower makes the first recurring payment on time, you can be guaranteed an 80% payout during the payment period.
Do you want to enroll with our "bad credit / billing plan" lenders? *
Merchant Services Offer:

We have partnered with a Merchant Processing company that can provide your Practice with credit card processing with no fees to your Practice. Note: fees are passed on to the card holder.
Would you be interested in learning more about the "no costs" credit card processing program?*
Non-Circumvent Agreement
Non-Circumvent Agreement: Credit Technologies, Finance Your Care and Chiro Credit work very closely with lenders at all credit levels and all over the United States. When we feel that a lender will be a benefit to your Practice, we will introduce you to the lender(s), and have you complete a direct enrollment. However, after the lender introduction, you cannot go around our company(s) and develop a direct relationship to avoid paying our User Fee as described below. If you do, we will be entitled to charge you a 10% fee on every closing you complete with the lender in the future. Do you understand the terms of this Non-Circumvent Agreement?*
Final Steps:

After you submit this form, we will review your answers and then email you back a welcome letter that includes the lender options we believe will be to be your best options. You will need to start each lender onboarding enrollment and provide any documentation they require. As soon as you have completed the enrollments, we will finish developing your financing platform and do a training with you and your staff. PLEASE NOTE: We have no control over what the lenders may ask you to provide and/or how long they may take to get your practice approved. This process can take up to 30 days. If you have any questions, please call (844) 995-4657. Thank you!
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Enrollment Agreement and Questionaire

Practice Information:

Your Current Financing Options

Programs you are interested in learning about:

Our Lender Options and Fees:

Prime Lenders (685 and up)

Off-Prime Lenders (Down to 620)

Fair Credit Lenders (Down to 580):

Poor Credit Lenders (down to 500)

Bad / No Credit Lenders (Billing Plan):

Merchant Services Offer:

Non-Circumvent Agreement

Final Steps: