Apply Now

"*" indicates required fields

Legal Entity Name*

Business Address*

Street Address City State ZIP / Postal Code

Business Phone Number*

Website

Time In Business*

State Of Incorporation*

Email Address*

Tax ID*

Contact Name and Title*

Principal's Info:

Owners Legal Name*

Home Address*

Street Address City State ZIP / Postal Code

Cell Phone*

SSN*

Date of Birth*

% of Ownership

Email Address*

Medical License # - State - Year Licensed

Is there an additional principle?*

Additional Principal's Info

Owners Legal Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone

SSN*

Date of Birth*

Ownership

Email Address

Medical License # - State - Year Licensed

Vendor Info:

Supplier/Vendors Name*

Equipment Description*

Cost of Equipment

Sales Rep Info*

By submitting your application via this website, the undersigned individual, who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction to Prime Health Financial Or its designee (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A Photostat or facsimile copy of this authorization shall be valid as the original. By submitting your application via this website, I/we affirm my/our identity as the respective individuals identified in the above application.

Phone

This field is for validation purposes and should be left unchanged.