Refer a Provider

If you would like to use the CareCredit program but your healthcare provider does not offer it, please take a moment to fill out the referral information below. We will contact the provider on your behalf to discuss the benefits of offering CareCredit.

By completing this form, you agree that we may use your name and the information below in our discussions with your provider.

***Our enrollment process strives to add your provider as quickly as possible. Please be sure to complete the information below so we can contact your provider.

However, if you have an immediate need, please click here to find a list of providers that you can use your CareCredit benefits today.

Your Information




( ) -

Yes No

Who will be the patient?
Myself Family Pet Other

When is your scheduled appointment?
2 Weeks 4 Weeks 4+ Weeks Not scheduled

Referred Practice Information



 Phone:  ( ) -



Address Information:



United States