Fillable Patient Financial Application Form

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Patient Financial Application Form

On average this form takes 19 minutes to complete

The Patient Financial Application Form form is 1 page long and contains:

  • 1 signature
  • 0 check-boxes
  • 72 other fields

Country of origin: OTHERS
File type: PDF

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Patient Financing - Financial Information Sheet
This is not an application. However, by completing this form, you are providing us consent to use this information to check your credit eligibility.
Applicant Questions Today's Date
Applicant was recently turndown for third-party financing? Date of First Office Visit
Yes No If Yes, Application Key # Office Site Code
Service Type Patient Chart No.
General Services Orthodontics/Invisalign Max Treatment Cost $
Length of Treatment
Patient Name Approve Credit Line $
Financial Source
Applicant Name
Prefix First Name Middle Initial Last Name Suffix
Personal Information
Date of Birth (MM / DD / YYYY) Social Security Number (XXX-XX-XXXX) Email Address
@
Driver's License Number State Expiration Date (MM/YYYY)
Contact Information
Current Street Address Suite/Apt # City State Zip Code
Previous Street Address
Suite/Apt # City State Zip Code
Housing Type
Home Phone (XXX-XXX-XXXX) Mobile Phone (XXX-XXX-XXXX)
Own Rent Other:
Move-in Date (MM/YYYY) Work Phone (XXX-XXX-XXXX) Message Phone (XXX-XXX-XXXX)
Income
Employment Status (Check one)
Employed Unemployed Homemaker Student Disabled Military Other
Employed By Date of Hire (MM/YYYY)
Annual Gross Income Monthly Net Income*
$ $
*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
Other Information Reference 1
Language Preference First & Last Name Contact Number (XXX-XXX-XXXX)
English Spanish
Reference 2 (Required when No SSN or No Credit Check)
Would you like to receive information and special offers in the future? First & Last Name Contact Number (XXX-XXX-XXXX)
Yes No
I, __________________________________, acknowledge the above information is correct.
Print Applicant Name
Signature _________________________________________________
Date ________________________________
OFFICE USE ONLY
PatFin-2016-02-11
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Patient Financial Application Form

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Completed 21 July 2020

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