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Please note that this form is for Practices who wish to enroll in CareCredit or request information. Information on becoming a CareCredit cardholder can be found by clicking here. If you are already enrolled with CareCredit and are wanting to submit an online application for your patients, please click here or call 800-839-9078.
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Enroll My Practice

Please Send Information

Please enter your practice information below.

Professional Corporation Name: *

Primary Contact Name:

Doctor Name:

Office Manager Name:

Business Fax #:

Office Phone #: *

E-mail Address: *

E-mail Belongs To:

Website Address:

Business Address:

City:

State:

Zip Code:

Professional Degree:
(Please specify Dental, Veterinary, Vision Care, Other)

Healthcare Specialty:

Years in Practice:

Type of Ownership:

Number of Employees:

How did you hear about CareCredit?

If you were referred, please enter the name of the individual/practice that referred you:

Thank you for initiating your enrollment. A representative will be in contact with you shortly to complete this process or to provide additional information.

Thank You!

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