MedChoice Financial - Patient Financing, Cosmetic Surgery

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MedChoice Financial - Patient Financing for Cosmetic Surgeries	Home Patients Providers FAQ's MedLease

Provider enrollment.

To enroll in the MedChoice Platinum patient financing program:

Via Fax

To enroll by fax download the PDF document. Print the enrollment form and fax it back to 1(866)637-7843

Via Online

To enroll online please fill out and submit the form information below.

Doctor's name:
Practice name:
# of years in service:
Practice address:
City:
State:
Zip:
Phone:
Fax:
Medical license #:
License state:
Financial contact:
Board certifications:
Do you have other practices?	yes no
Shall we enroll other practices?	yes no
Other physicians in your practice?	yes no
Name of other physicians:
Name of person submitting form: