Hospital Jerusalem

Financing Application Form

Physician / Surgery Information
 
Type of procedure: Tentative procedure date
   
Amount requested: Deposit ( if any ):
$  
Physician name: Physician phone:  
 
Practice name: Physician fax: Office contact name:
     
Patient information    
     
Name:
Middle name: Last name:
E-mail Date of birth:  
Social security # Home phone: Work Phone: Ext:
Cell phone: Marital status  
 
Current home address:
City: State Zip code:
 
Credit card information
Is not required and will not be charged, however it will expedite your loan response time.
   
Credit card type: Credit card #:
     
Monthly rent / morgage Own / rent / other Time at residence:
$ Years Months
   
Employment information  
   
Employer / company name: Occupation:
Time at employment: Annual Salary:
Employer address:  
City: State Zip code:
     
Other MONTHLY incomes:    
     
Verifiable additional income(s): Child support:  
 
     
Retirement or pension: Other job(s):  
 
 

By Submitting this application I have verified that all informaion submitted on this application is true and correct to the best of my knowledge, as well as allowing SurgeryLoans.com and/or its Lender(s) to verify the enclosed information, including, but not limited to, obtaining my credit
report, contacting my employer to verify employment and income, and/or contacting my Physician to verify the type of procedure(s), procedure date, deposit amount, procedure amount and remit payment on approval.

I understand and agree that the Lender(s) (as defined in the Promissory Note of communication to me) can furnish information. Furthermore, I am signing that Physician staff may apply on my behalf. I have read this disclosure and agree to all terms set forth.
 

Patient Liaison

Louise Johnson
Available 24/7 for your convenience !

Toll Free:+1 866 806 4286
Direct #:+1 727 423 5662
FAX:+1 772 324 8336
E-mail:info@hospitaljerusalem.com.mx