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Patient application form

<h2>Use of your information</h2>
We work with no more than two finance providers.
In considering your application you authorise us to refer your application to third party finance providers and share information with Your healthcare provider as detailed in Your application. Within this paragraph all references to ‘we’ or ‘us’ will be deemed as including such finance and healthcare providers.
We will use a credit scoring or other automated decision-making process when assessing your application.
In considering your application we will search your record at credit reference agencies. They will add to your record the details of the search and your application and this will be seen by other organisations that make searches.
Information held about you by the credit reference agencies may already be linked to records relating to one or more other persons.
For the purpose of this application you may be treated as financially linked and your application will be assessed with reference to any associated records.
If you are a joint applicant or if you have told us of some other financial association with another person you must be sure that you are entitled to disclose information about your joint applicant and anyone referred to by you, authorise us to search, link or record information at the credit reference agencies about you and anyone referred by you.
An association between joint applicants and between you and anyone you tell us is your financial partner will be created at the credit reference agencies.
This will link your financial records, each of which will be taken into account in all future applications by either or both of you. This will continue until one of you successfully files a disassociation at the credit reference agencies.
We will also add to your record with the credit reference agencies details of your agreement with us, the payments you make under it, any default or failure to keep to its terms and if you give us false or inaccurate information and we suspect fraud we will record this.
These records will be shared with other organisations and used by them to help make decisions about credit and credit related services such as insurance for you and persons with whom you are financially linked, trace debtors, recover debt, prevent money laundering and fraud, and to manage your accounts.
The credit reference agencies and fraud prevention agencies will also use the records for statistical analysis about credit and about insurance and fraud.
Fraud prevention agency records will also be shared with other organisations to help make decisions on motor, household, credit life and other insurance products and insurance claims for you and persons to who you are financially linked. When we have processed your application, we will only retain and use your information in accordance with our Privacy Policy, which also confirms your Rights in accordance with the Data Protection Act and General Data Protection Regulation (GDPR).
A copy of our Privacy Policy is available on our website, by emailing us at dentalfinance@financingfirst.co.uk , calling us on 03452 591091 or writing to us at The Oaks, 27 Applecroft, Park Street, St Albans, Herts. AL2 2AP.
Each applicant warrants and certifies that all the details on this form are true. You authorise us to make payment direct to your healthcare provider as detailed in Your application.
You acknowledge that your healthcare provider may be informed of any arrears and authorise your healthcare provider to discuss any aspects of the transaction and related treatment with us.

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In completing this application for Dental Finance I confirm that I have read the ‘Use of Information’ Statement and accept how my information will be used in order to assess my application.

(* indicates a mandatory field)

I agree*

Yes Please agree with the statement

Is this application being filled in at the practice?*

YesNo Invalid Input

Please complete the application form and then click on 'submit' on the final page.

Please give us details of the practice where you will receive treatment

(* indicates a mandatory field)

Practice name: *

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Practice Tel. No: *

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Supplier No (if known):

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Purpose: *

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Other details, please specify*

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Total price of treatment: *

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Deposit to Practice: *

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If deposit paid, did you use a credit card?

YesNo Invalid Input

Amount of finance required:*

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Repayment term: *

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Interest (APR): *

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Monthly repayment: *

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Your details

(* indicates a mandatory field)

As part of the process your practice will need to verify your signature and address. There is no need to try to attach any documentation to this application.

Proof of signature- please confirm what card you will present by typing in the first 6 digits and the last 4 digits of your card number in this box.*

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Proof of address - please confirm what you will present. It can be one of the following - Driver's licence (type in licence number), Bank or Card statement (type in Bank name and date), Utility or Council tax bill (type in Provider/Council name and date).*

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Title: *

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Forename: *

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Middle name

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Surname: *

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Date of birth: *

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Former surname

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House number/name:*

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Street: *

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Town: *

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Postcode: *

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Preferred contact telephone number*

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Preferred telephone number: *

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email address: *

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If you would like to e-sign the Credit Agreement please provide the following information:

Password (At least seven characters including a capital letter and a number)

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Place of birth

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Have you lived at your current address for more than three years?

Yes/No*

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Time at current address - years *

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Months*

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Previous house number/name: *

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Previous road: *

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Previous town: *

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Previous postcode: *

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Time at previous address - years *

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Months*

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Marital status: *

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Number of dependents aged under 18:*

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Residential status: *

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Do you have a mortgage?*

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Time you've held your mortgage - years *

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Months*

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Applicant's bank details

(* indicates a mandatory field)

Bank sort code: *

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Bank account number: *

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Debit card held: *

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Time with bank - years *

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Months*

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Number of credit cards held: *

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Employment or self employment details

(* indicates a mandatory field)

Your employment status: *

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If part time, you must work at least 16 hours per week.

If you are a house person, please enter your spouse's or partner's details.

Employer's name: *

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Telephone number: *

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Time with employer - years *

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Months*

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Job title: *

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Employer's address:

Building number/name: *

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Branch/department:

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Street:*

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Postcode or town:*

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Gross annual income: *

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Self employed address

Business name: *

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Business Telephone number:*

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Type of business: *

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Time self employed - years *

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Months*

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House or building number: *

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Street: *

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Town: *

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Postcode: *

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