Financing Pre-approval Form

First Name *

Last Name *

Date of birth *

Social Security Number *

House/Apartment Owned or Rented *

Own

Rent

Address *

City *

State *

Phone *

Email *

Postal code *

Housing Monthly Payment *

Employer *

Net Annual Income *

State ID *

I confirm and approve the use of the Patient Financial Pre-Approval Form for the purpose of obtaining preapproval for dental financing options. I understand that by completing and submitting this form, I am requesting information on potential financing options to cover the cost of my dental treatment.

I acknowledge that the information provided in this form will be used to assess my eligibility for financing programs offered by third-party lenders or dental financing companies. I understand that the preapproval process will require sharing my personal and financial information with these lenders or financing companies for evaluation purposes.

I confirm that all the information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that any misrepresentation or omission of information may affect my eligibility for financing options.

I am aware that the preapproval for dental financing options is subject to the lender's or financing company's approval criteria, terms, and conditions. I understand that the final approval and terms of any financing agreement will be determined by the lender or financing company.

I acknowledge that the dental financing options presented to me will have associated costs, interest rates, fees, and repayment terms. I understand that it is my responsibility to review and understand the specific terms and conditions of any financing agreement before agreeing to it.

I confirm that I have read and understood the Terms and Conditions related to the use of the Patient Financial Pre-Approval Form for dental financing options. I agree to abide by these terms and conditions and accept any financial responsibilities that may arise from the financing agreement.

By signing this confirmation and approval, I give my consent for the dental provider to assist me in obtaining preapproval for dental financing options and to share the necessary information with relevant third-party lenders or financing companies.