Patient Financing

Welcome to Kois Center’s patient financing program!

There are two parts to this process.

Please complete the below form.
Upon completion, you will get access to another form that will be sent to the lender for approval. Approvals will usually occur within 24 hours.

Step 1: Patient & Dentist Information

Patient Name*
Prefix First Last
Patient Phone*
Patient Email*
Enter Email Confirm Email
Dentist's Name*
Prefix First Last
Practice Email*
Enter Email Confirm Email
Practice Phone*
Practice Address*
Street Address Address Line 2 City State ZIP Code
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