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Olde Oakville Dental
 
 
 

Financing Application Form

Dentalcard is Canada’s preferred dental financing company for over 20 years!

We finance all treatments at Olde Oakville Dental. You can request financing for a portion or Dentalcard will finance the complete procedure.

Go ahead ... Now you can afford to!

Fields marked with * are required fields

GENERAL INFORMATION
You are: The Applicant     The Cosignor
Your preferred language
of communication:
English     French
Mr.   Mrs.   Ms   Miss  
First Name: *
Middle Initials:
Last Name: *
Email Address:
Date of Birth: *        19 
Social Insurance Number:
Driver's License Number:
Home Phone:
Day Phone: * Extn:
Fax Number:
Call Before Fax? Yes   No   
Personal Reference Name #1:
Personal Reference Phone #1: Extn:
Personal Reference Name #2:
Personal Reference Phone #2: Extn:
CURRENT ADDRESS
Apt. Number:
Address: *
City & Province: *   
Postal Code: *
Residing Since:   
    Own      Rent
Monthly Payment: $
Landlord or Mortgage Company:
EMPLOYMENT INFORMATION
Occupation:
Employer:
Employer Contact Person:   
Business Phone: Extn:
Employee Since:   
Status:
Gross Monthly Income: $
Net Monthly Income: $
OTHER INCOME
Source:
Amount/Month: $
PROCEDURE INFORMATION
Name of Patient (if applicable):
Amount of Financing Required: $
Term:   
Procedure or Product
or Service Type:
Approx. Date Funds Required:   
Clinic or Dentist or
Service Provider:
Contact Person:
Phone: Extn:
Fax:
ADDITIONAL INFORMATION
How did you hear about us?:
If you require an immediate answer or have special instructions or information, please indicate in the space below:
If you have any further information, or have any questions, please contact us at 1-888-689-9876 and we will be happy to assist you
TERMS & CONDITIONS



   

Easy steps to apply for financing?

Dentalcard's financing program ensures that you don't delay your treatment due to cost concerns by offering you a variety of financing terms.

 

With Dentalcard you get the best benefits:
High approval rate
Competitive interest rates
Quick, confidential process
Low monthly payments
No prepayments penalty

Questions?

Call customer service:
1 888 689 9876