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Provider Application

Financing Solutions

Merchants

Doctors and Patients

Hospitals

Corporate Site


eMedical Financing Solutions offers 100% payout to your office. There are no fees, loan discounts or recourse to your office. Our process is simple. Once you enroll into our program, we will send you a welcome package that includes everything you need to offer financing to your patients. Once your patient submits a loan application, we take care of everything else, including making sure you are paid prior to the procedure date. To enroll in our program, fill out the following form and submit. One of our representatives will follow up with your office after you receive the welcome package.
Provider Information
Office or Practice Name:
Dr(s) Name:
Patient Coordinator or Office Manager:
Address:
 
City:
State:
Zip:
Phone:
Fax:
Email:
Web Site URL:
Make Checks Payable To:
Do you require multiple checks: Yes No
Would you like to offer patient financing from your website? Yes No
No website...Would you like information about website packages? Yes No
How were you referred to our site?    Name/Source:
Notes