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Health Credit Assessment
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First Name
*
Middle Name
Last Name
*
Consent
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You understand that this is not an application for credit and will not effect your credit score
*
You understand that by providing a signature below, you certify that all the information provided is true and correct, and you are confirming you have read and understand the
Privacy Policy
and you are providing written instructions to this practice under the FCRA authorizing this practice to obtain information from your personal credit profile from one or more credit reporting agencies. You authorize this practice to obtain such information solely to conduct a prequalification for credit for your health credit assessment.
Signature
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*Signature is required
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Date: 4/1/2026
payments provided by
PatientPayments™
| View our
Privacy Policy
payments provided by PatientPayments™ | View our Privacy Policy