Plastic Surgery Financing Information - Dr Jay M Pensler

680 North Lake Shore Drive
Suite 1125
Chicago, IL 60611
312.642.7777

Plastic Surgery Credit Application

To apply for financing of your plastic surgery procedure please fill out the form below, review the disclosures and provide your digital signature.

If you have any questions contact our patient coordinator at 312-642-7777.

- All Fields are Required.

PRODUCT SELECTION:

Loan Installment Options:
	No prepayment penalty, fixed rates starting at 1.9% APR*

PATIENT INFORMATION:

Full Name (First, M, Last):
Social Security Number:
Date of Birth: Format: January 1, 1975:
Street Address:
City:
State:
Zip Code:
Home Phone:
Email Address:
Do You OWN, RENT or LIVE W/ PARENTS?:
If OWN or RENT, what is Monthly Payment?
Are You Employed or Not Employed?:
Employer Name:
Position:
Work Phone:
Gross Annual Household Income Per Year:
Type of Surgery:
Surgery Amount $:

CO-APPLICANT	- Please fill in all fields of co-applicant below.
Full Name (First, M, Last):
Social Security Number:
Date of Birth: Format: January 1, 1975:
Street Address:
City:
State:
Zip Code:
Home Phone:
Email Address:
Do You OWN, RENT or LIVE W/ PARENTS?:
If OWN or RENT, what is Monthly Payment?
Are You Employed or Not Employed?:
Employer Name:
Position:
Work Phone:
Gross Annual Household Income Per Year:
	By submitting this form you agree to the following terms and disclaimers, and authorize Dr. Pensler's staff to submit this form on your behalf for underwriting approval.