HEALTH ONE CARD
     
  To begin utilizing the patient financing program offered through Health One Financial, please complete each section of this form to ensure that we receive all of your information.  If you have any questions, please contact technical support at 888-748-3621 or email us at customer.support@HealthOne-Financial.com.
 

  PROVIDER INFORMATION
           

Practice Name

    

Doctor Name #1

  

Address

    

Doctor Name #2

  

City

    

Doctor Name #3

  

State

    

Doctor Name #4

  

Zip

        
         

  CONTACT INFORMATION
     

 

  

Office Phone Number

  ()  -  

Primary Contact

  

Office Fax Number

  ()  -  

Email Address

  
         
  OFFICE INFORMATION
         
 What Types of Surgery Does Your Office Perform?      

Dermatology Surgery

 Eye Surgery   Hair Transplant Facelift
Orthodontics Lasik, PRK, etc.   Liposuction Hair Removal
Cosmetic Dentistry Breast Surgeries   Bariatric Surgery Other (Please List)

Rhinoplasty

 General Cosmetic Surgery  

IVF & Fertility

  
         
       

 What Certifications Does Your Practice Hold?

     
American Society of Aesthetic Plastic Surgery   American Board of Surgery
American Society of Plastic Surgeons   American College of Surgeons

American Board of Plastic Surgeons

   Other Certifications or Affiliations (Please List)

American Academy of Cosmetic Dentistry

    
     
Are you currently working with a finance company?     
Number of patients referred for financing per month?      /month
Average cost of financed surgery?    $/surgery
         
       
         

Please note that this is not a contract.  Completion of this form provides Health One Financial with information about your office to process your request.

 

 

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