Welcome, and thank you for your interest in Belcara Health.
Applicant and patient must be 18 years of age. Please ensure all fields below completed. Depending on the loan program you qualify for a revolving credit account may automatically open in your or your Co-Applicant's name.
First Name *

Last Name *

Cell Phone *

Home Phone

Date of Birth *

Social Security Number *

Driver's License Number

Driver's License Expiration Date

Married or Single?

If necessary, are you able to provide a co-applicant?

Medical Procedure *

Financing Amount Requested *

Surgery Date

Surgeon's Name

If you haven't selected one, don't worry. Just leave this blank.
Time to tell us your current address...

Don't worry. You're almost done.
What street do you live on? *

If it's an apartment, please include the unit number.
City *

State *

Zipcode *

How long have you lived there? *

Own or Rent? *

Monthly Rent or Mortgage Amount *

Now, a little bit of information about your current employment, okay?

Employer Name *

Employer Phone Number *

What's your position? *

How long have you worked there? *

Gross Income from Job *

Please indicate per year or per month.
Other Income

If you have additional monthly income, please share the monthly amount and source.
Are you applying as a co-applicant?

If so, please enter the patient's name and your relationship to the patient. If not, leave this blank.
Authorization of Credit Information and Credit Policies Release

By submitting this application (the "Application"), I confirm that all information submitted and contained in the Application is true and correct to the best of my knowledge. I authorize BELECARA ("BELECARA") and/or any Lender(s) to which the Application is submitted (individually a "Lender" and collectively "Lenders") to verify the submitted information by appropriate means, including, but not limited to, obtaining my credit report and other financial information and making contact with my employer for employment and income verification. I authorize BELECARA or any Lender to contact my Physician to verify the procedure type(s), procedure date, amount of deposit, amount of procedure(s) and remit payment on approval. I authorize BELECARA or its agents to search various sources for financing on terms which BELECARA, in its sole discretion deems to be consistent with better terms in the marketplace for such financing (the "Financing") and to apply for Financing on my behalf. I understand and agree that BELECARA may forward my application to various Lenders including, but not limited to, banks, finance companies, credit card issuers and any partnership program affiliated with "Lending Tree" and similar entities, as BELECARA or its agents, in their sole discretion, deem appropriate. (to I authorize BELECARA, its agents and any Lender to provide information regarding my account to consumer reporting agencies and others who may appropriately receive that information and to exchange confidential, non-public, personal financial and medical information about me for purposes of obtaining Financing. I authorize BELECARA to apply to any Lender on my behalf for Financing. I also warrant and represent that I have full authority to include all information regarding any co-applicant on the Application and further agree that I am authorized to permit and hereby do further authorize BELECARA and/or any Lender to investigate the creditworthiness of such co-applicant . I understand and agree that a revolving credit account may be opened automatically in my name or my co-applicant's name, depending on the loan program that I qualify for. I understand that the co-applicant may become the primary obligor under any Financing, depending on my credit status in relation to the co-applicant's credit status. I understand and agree that APR rates vary by credit rating and/or loan terms selected, that loan approvals are available for a limited time only and that all decisions regarding the extension or denial of credit are within the sole discretion of Lenders. I further release and hold BELECARA, its directors, officers, employees and agents harmless from and against any and all claims or causes of action relating to or arising, directly or indirectly, from any action or inaction of any Lender or other third party, prior or subsequent to obtaining Financing, including but not limited to the extension or denial of credit by any Lender, in connection with the Application or the Financing.