Patient forms

Borrower Mailing Address

*we promise not to share your email with anybody.

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33%

Social Security Number

*we promise not to share your email with anybody.

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66%

Miscellaneous

Select locationSurprise, AZMesa, AZTucson, AZTucson East, AZChandler, AZGlendale, AZ

I hereby certify that all the information entered above is true and accurate as provided by the borrower and no attempts have been made by me to alter/falsify this information. I further certify that the borrower has given consent to allow any financial institution (including but not limited to Wellness Dental) to whom this application will be submitted to obtain credit reports for the borrower from various Credit Reporting Agencies and to share all the information contained in this application with other financial institutions, partners and affiliates. Additionally, the borrower has given consent to receive certain disclosures and documents electronically from these financial institutions at the email address and/or mobile phone number specified in this application. You also certify that all legally required disclosures, including CIP Notice, have been provided to the borrower.

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