Finance Application
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Patient Info
Patient First Name
Patient Last Name
Applicant Info
Legal First Name
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Legal Last Name
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Phone
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Email
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Social Security Number
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Date of Birth
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Address
Street Address
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State
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City
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Postal Code
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Gross Annual Income
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Housing:
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Mortage/Rent Payment
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Employment Status
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Employer Name
Occupation Title
Drivers License Issue State
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License Exp MM/YY
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By Signing below, I understand and agree to the following: I authorize NuTeeth Implant Centers and/or its designated financing partners to run credit checks, verify income or financial information, and share necessary information to facilitate financing approval. I acknowledge that approval, terms, interest rates, and payment schedules are determined by the financing provider and are not guaranteed. I agree to be financially responsible for all charges incurred for services rendered, regardless of insurance coverage or financing approval. This authorization shall remain in effect unless revoked by me in writing. By signing below, I confirm that I have read, understand, and agree to the terms outlined above.
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