Get the care you need now!
Dentalcard customer
Dentist or service provider
Service Provider
Couple who applied for loan for dental work
 
 
 

Financing Application Form

Fill out our secure online form below or CLICK HERE for a pdf form that you can complete and fax or mail to us.

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:
Social Media Handles
Twitter Handle:
Facebook Handle:
Instagram Handle:
LinkedIn Handle:
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 prepayment penalty

Questions?

Call customer service:
1 888 689 9876