Skip to main content

Provider Referral

Get Started

If you would like to use the CareCredit program but your healthcare provider does not offer it, please take a moment to fill out the referral information below. We will contact the provider on your behalf to discuss the benefits of offering CareCredit.

By completing this form, you agree that we may use your name and the information below in our discussions with your provider.

***Our enrollment process strives to add your provider as quickly as possible. Please be sure to complete the information below so we can contact your provider.

However, if you have an immediate need, please click here to find a list of providers that you can use your CareCredit with today.

1

Your Information

Error Cardholder name required
Error Email address does not match
Are you a CareCredit cardholder?
Error Please specify whether or not you are a CareCredit cardholder.
Who will be the patient?
Error Please select "Who will be the Patient?"
When is your scheduled appointment?
Error Please select "When is your scheduled appointment"
2

Referred Practice Information

Error Contact Name cannot be left blank
Error Contact Last Name cannot be left blank
Error Please select a Contact Title
Error Please enter a Doctor/Practice Name
Error Your referred phone number you entered was invalid
Error Please select a Practice Type

Address Information:

Error Please enter a Practice Address
Error Please enter a city
Error Please select a state
Error Please enter a valid Zip Code
Country
back to top