CareCredit® Healthcare Finance - Refer a Provider (Payment Plans for Cosmetic Surgery, Dental, Vision, Hearing, Veterinary & More)

Patient Services

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.

*Indicates a required field.

Your Information

Your Name*

Email Address (optional)

I am *

Email Address (confirm)

Providing an e-mail address will allow us to contact you for a status on when your provider enrolls.

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

Contact Name*		Contact Title*
Doctor/Practice Name*
Phone*	() -
Profession*		(Select a Profession)
Country*
Address
City	State
Zip
City
Province		Postal Code

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Your Information

Referred Practice Information

Estimated Procedure Amount