Clone of Enrollment Agreement and Questionaire

Enrollment Agreement and Questionaire
Thank you for your interest in enrolling with Credit Technologies / Finance Your Care. 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?*
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 and the fee(s) they charge on each funding. If you are not offering Patient Financing at this time, just enter "None".*
About the service we provide:

Finance Your Care is a member of the Credit Technologies family of "Fin Tech" companies. The service we provide to your Practice is a technology platform that provides you with the ability to pre-qualify the Applicant with multiple lenders simultaneously. Finance Your Care is not a lender, and we do not extend credit in any form.
Enrollment Options:

Based on the area of the country you are located in; you may have two enrollment options. The first option is available nationwide. With this option, we do not charge your practice any fees and you end up getting paid 100% of your fee with most loan closings. This is accomplished by your patient being responsible for paying all the fees. The second option (in limited markets) is based on a 12-month subscription to use our technology. With this option, we do not charge your patients any additional fees. However, your practice is charged a flat monthly fee of $475 plus $15 per application starting with the eleventh application you run in any single month.
Do you have a preferred enrollment option? *
Refundable Set-up Fee Deposit:

Finance Your Care spends a good amount of time and incurs significant costs when setting up a new practice to use our service. As such, we cannot have a practice enroll "just because it is free". For that reason, we collect a $575 set up fee upfront when you enroll. But then after you have closed and funded 5 transactions using our service for which we have collected a processing fee, we credit the $575 back to you.
Do you understand and agree to our Refundable Set-up Fee Deposit? *
Final Steps:

After you submit this form, we will complete your onboarding with Finance Your Care, and assign your Practice with a Provider ID. After doing so, we will send you back two emails. The first email will be with your Provider ID and the invoice for the $575 deposit. The second email will be the onboarding instructions for our lender partners. If you have any questions about either of these, please call (844) 995-4657. Thank you!
FYCNOW
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Enrollment Agreement and Questionaire

Practice Information:

Your Current Financing Options

About the service we provide:

Enrollment Options:

Refundable Set-up Fee Deposit:

Final Steps: