Treatment Finance Account Opening Form

    About Your Business

    Director/Business Owner Details

    First Director/Partner

    Second Director/Partner

    Third Director/Partner

    RELEVANT PRACTICE SUPPORT STAFF CONTACT NAMES (for day to day business processing – Practice Manager, Head Nurse etc.)

    First Staff Member

    Second Staff Member

    Third Staff Member

    Person Responsible For Compliance

    Business Financial Information

    Total Turnover Last Year

    Total Turnover This Year

    Value of Patient Treatment Financed Last Year

    Value of Patient Treatment Financed This Year

    Please indicate average treatment value

    Bank Details

    Regulatory Information

    Financial Conduct Authority Authorisation

    Unregulated Notice

    All unregulated suppliers are required to abide by the same regulations as if they were Regulated, not limited to but including, Credit Advertising, Introduction of Finance, Sales Practice, Cancellation rights, adherence to Finance and Leasing Association code of conduct, Consumer Contracts (Information, Cancellation and Additional Charges) Regulations Act 2013, certain provisions of the Consumer Credit Act 1974 and The FCA Consumer Credit Source book “CONC”

    Professional and Regulatory

    Certificates Included

    Proof of Bank Identification

    Please upoad photo copy