Enroll Your Practice - CareCredit® Patient Financing for Doctors and Practices

Please note that this form is for Practices who wish to enroll in CareCredit or request information. Information on becoming a CareCredit cardholder can be found by clicking here. If you are already enrolled with CareCredit and are wanting to submit an online application for your patients, please click here or call 800-839-9078.

Thank You.

Enroll My Practice Please Send Information

Please enter your practice information below.

* Indicates a required field.

Professional Corporation Name: *

Primary Contact Name:

Doctor Name:

Office Manager Name:

Business Fax #:

Office Phone #: *

E-mail Address: *

E-mail Belongs To:
Doctor
Office Manager
Practice

Website Address:

Business Address:

City:

State:

Zip Code:

Years in Practice:

How do you plan to use CareCredit in your practice?:

If other, please specify:

Type of Ownership:
Corporation
Sole Proprietor
Partnership

Number of Employees:
1-5
6-9
10+

How did you hear about CareCredit?

Promotional Code:

If you were referred, please enter the name of the individual/practice that referred you: