Clone of Enrollment Agreement / Patient Pays the Fees

Enrollment Agreement / Subscription
Thank you for your interest in enrolling with 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.
Enrollment Option: Monthly Subscription

You have chosen to enroll in our program whereby your Practice will be responsible for paying a monthly subscription of $475 to use the Finance Your Care technology, plus $75 per funding. This program eliminates all fees to the patient/applicant unless you want to make them responsible to pay the $75 per funding fee. That will be your choice. NOTE: If you prefer to enroll in our Patient Pays all the fees program, close this form and click on the option for "patient pays" on the previous page.
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?*
About Your Practice and 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. If you are not offering Patient Financing at this time, just enter "None".*
About the service we provide:

Finance Your Care is a "Fin Tech" company. We DO NOT offer loans or have anything to do with the offers that may be made by a lender. 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 and then enter an application with the lender of your choice.
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 an email that will include your Provider ID and a request to schedule a call about your lender preferences. If you have any question, please call (844) 995-4657. Thank you!
Should be Empty:

Enrollment Agreement / Subscription

Enrollment Option: Monthly Subscription

Practice Information:

About Your Practice and Current Financing Options

About the service we provide:

Final Steps: