(855) 503-1800
1231 East Dyer Rd, Suite 210, Santa Ana, CA 92705
Services Financed
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Services Provided
Plastic & Cosmetic Surgery Financing
Dental Financing
Bariatric Financing
Fertility Financing
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Hearing Aid Financing
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*
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Midwifery
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Amount Requested
*
$
Between $1,000 and $35,000
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*
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Date of Service
Date of Service must be within
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. If not yet set, please provide an estimate. Some approvals are only valid for 30 days.
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A 2nd applicant may be added later in the application.
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*
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*
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Person Receiving Services
?
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*
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Person Receiving Services
under 18 years of age?
*
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*
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*
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Email
*
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1919
Housing Status
*
Own
Rent
Military Housing
Live With Parents
Monthly Mortgage or Rent Payment
*
$
Reference
Name of Reference
*
Not living with you
Relationship to Reference
*
Parent
Grandparent
Sibling
Aunt/Uncle
Other relative
Friend
Phone Number of Reference
*
(
)
-
Address of Reference
*
City
*
State
*
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Zip Code
*
Source of Personal Income
Employment Status
*
Select...
Employed
Self Employed
Homemaker
Retired
Student
Unemployed
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Other
Tax returns required. Total Gross Monthly income should be based off Adjusted Gross Income on returns.
Total GROSS Monthly Income (Before tax)
*
$
Input the GROSS income you personally receive
MONTHLY
from your employment
. Income may be subject to verification.
DO NOT
list household income.
Annual Income
$
Please
confirm
this is correct
Employment Details
Employer Name
*
Employer Phone Number
*
(
)
-
Occupation
*
Start Date at Current Job
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
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2015
2014
2013
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2000
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1979
1978
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1936
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
How often are you paid?
*
Weekly
Bi-Weekly
Twice Monthly
Monthly
Start Date at Previous Job
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
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1973
1972
1971
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1968
1967
1966
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1951
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
Finish Date at Previous Job
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
Other Personal Verifiable Income (Monthly)
$
You
DO NOT
need to include other personal verifiable income unless you want it considered as a basis for loan repayment.
2nd Applicant
Add a 2nd Applicant?
*
Yes
No
Relation to Applicant
*
Spouse
Mother
Father
Son
Daughter
Domestic Partner
Co worker
Boyfriend
Girlfriend
Friend
Grandmother
Grandfather
Uncle
Sister
Brother
Cousin
Aunt
Nephew
Niece
Fiance
Step-Mother
Step-Father
Sister-in-law
Brother-in-law
Mother-in-law
Father-in-law
If you feel you have non-qualifying credit for this pre-qualification, please add a 2nd Applicant. United Medical Credit may come back with an offer listing the 2nd applicant as the Primary signer if the first applicant does not qualify
About the 2nd Applicant
First Name
*
Last Name
*
Date of Birth
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Date
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
Social Security Number
*
-
-
We use 128 bit SSL protection and additional encryption to keep your information safe.
Email
*
Please enter the 2nd Applicant's correct personal email address to avoid delays with processing
Cell Phone Number
*
(
)
-
At least one contact number required
Home Phone Number
(
)
-
Where the 2nd Applicant Lives
Same address as applicant
Physical Address (no P.O. Boxes)
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Current Residence Move in Date
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
Housing Status
*
Own
Rent
Military Housing
Live With Parents
Monthly Mortgage or Rent Payment
*
$
2nd Applicant Employment
Employment Status
*
Select...
Employed
Self Employed
Homemaker
Retired
Student
Unemployed
Military
Other
Tax returns required. Total Gross Monthly income should be based off Adjusted Gross Income on returns.
Total GROSS Monthly Income (Before Tax)
*
$
Input the GROSS income they personally receive
MONTHLY
from employment
. Income may be subject to verification.
DO NOT
list household income.
Annual Income
$
Please
confirm
this is correct
2nd Applicant Employment Details
Employer Name
*
Employer Phone Number
*
(
)
-
Occupation
*
Start Date at Current Job
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
How often are they paid?
*
Weekly
Bi-Weekly
Twice Monthly
Monthly
Start Date at Previous Job
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
Finish Date at Previous Job
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
Other Personal Verifiable Income (Monthly)
$
You
DO NOT
need to include other personal verifiable income unless you want it considered as a basis for loan repayment.
2nd Applicant Reference
Name of Reference
*
Relationship to Reference
*
Parent
Grandparent
Sibling
Aunt/Uncle
Other relative
Friend
Phone Number of Reference
*
(
)
-
Address of Reference
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
*
Required field
Agreement
By clicking the SUBMIT APPLICATION button, you are providing written consent under the Fair Credit Reporting Act for United Medical Credit and our lenders and partners with whom you are matched to obtain consumer reporting information from your credit profile or other information from one or more credit bureaus. You understand and agree that you are submitting an application for credit, and are consenting to the use of your consumer report information by United Medical Credit and our lenders and partners to conduct anti-fraud security checks and evaluate your application for credit. You understand that your application may be matched with multiple lenders, each of whom may obtain consumer report information from your credit profile.
Due to lender policies the person who is receiving the services is required to be listed as the main applicant if 18 years of age or older. If you believe the person who is receiving the services has non-qualifying credit, an option to add a 2nd applicant is provided at the end of this application. Funding may be canceled or declined if the person receiving the services is over the age of 18 and is not on the application (if the person receiving the services is a minor, please list the minor's legal guardian as the primary applicant).
SMS Terms and Conditions for Application Alerts: The United Medical Credit SMS alert program sends text reminders regarding the status of an applicants application throughout the process. United Medical Credit is not responsible for any charges from a person's service provider that may result from us providing this service. It is the applicants responsibility to check with their individual carrier, as standard messaging and data rates may apply. United Medical Credit assumes no responsibility for charges incurred by our text messaging service.
I have read, understand and accept the
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Terms and Conditions
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Additional Disclosures
and
Electronic Disclosure
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