7900 Glades Rd, Suite 340

Boca Raton, Florida 33434


Patient Finance Application

Three Easy Steps to Apply for Healthcare Financing

Applying for a health care loan is easy, fast and requires minimal information from the patient

  1. Patient Provides Payment Information – Patient provides patient payor demographic information.
  2. Patient Provides Loan Applicant Information and Desired Financing Amount – Patient confirms payor is same as loan applicant and enters amount of requested healthcare loan (minimum of $1,000).  Email address is required! Be sure to allow pop-ups on your web browser to continue to Step Three.
  3. Patient Confirms Identity  – The patient confirms identity via email or pop up window and completes the health care loan application process, including selecting the desired lender and convenient payment terms.  Please be sure to complete the application process so that you can receive funds to receive the health care you deserve – that’s it!  It’s that easy.

Payment Information - Step 1

First Name:

Last Name:

Email Address:

Billing Address:

Billing Address 2:



Zip Code:


Card Holder Name:

Card Number:


Expiration (MMYY):

The amount is the non-refundable application fee for Healthcare loan