Loan Application

This application only takes about 5 minutes to complete. The application fee is $25, which can be paid by credit card on the last step. This fee will be refunded if your application is declined. Debit cards are not accepted

Questions? Check our FAQs or contact us.

Patient's first name

Enter the first name

Patient's last name

Enter the last name

Patient's birthdate

Please enter a valid birthdate

Doctor's name (optional)

Requested loan amount (including any medications)

Enter an amount between $3,000 – $50,000

Repayment term

6 months 12 months 18 months 24 months 30 months 36 months 42 months 48 months 60 months

Select a term

I am the patient above and the primary borrower

I am applying for a loan on behalf of the patient above

Please make a selection

Borrower's first name

Enter the first name

Borrower's last name

Enter the last name

Borrowers relationship to the patient

Enter your relationship

Borrower's mobile phone

Enter a valid phone number

Borrower's email

Enter a valid email address

Continue

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