Web Application Form

Please Read "TERMS" Before Applying
"TAB" Through Fields, * = Required Field

Estimated Procedure Cost is required
First Name is required
Middle Initial is required or use N/A
Last Name is required
Suffix or N/A
Birth Date is required
First 3 digits
Next 2 digits
Last 4 digits
Email Address is required or N/A
Street Address or RR# is required
Apt / Unit is required or N/A
City is required
State is required
Zip is required
Home Phone is required
Work Phone is required
Cell Phone is required
Monthly Income is required
Any Additional Income & Source or N/A
Marital Status is required
Mother’s Maiden Name is required or N/A
Housing is required
Monthly Mortgage or Rent Amount required
Who Pays Monthly Mortgage Rent is required
Is Your Name On Mortgage Lease is required
Mortgage Holder or Landlord Name is required
You must select Yes or No
Bankruptcy Date is required
Any Foreclosure or Short Sale is required
Enter Year of Foreclosure or Short Sale in YYYY
Enter YEARS at current address is required
Enter MONTHS at Current Address
Prior Address If Less Than 2 Years is required or N/A
Time At Prior Address is required or N/A
Invalid Input
Enter YEARS at Employee is required
Enter MONTHS at Employee is required
Job Title is required or N/A
Supervisor is required or N/A
Proposed Procedure Date is required
Invalid Input
Driver License # or State ID # is required
State Driver License was Issued or State ID
Select Date
Personal Reference
Enter Your First Name
Enter MONTHS at Employee is required
Personal Reference Phone # is required
Personal Reference Relationship is required or N/A
You have to agree to the Terms & Conditions

AcQuired Loan Solutions

To help you get the credit you need, AcQuired stays current with the approval criteria and credit score requirements of lenders, starts with the most lenient lender(s), and offer insights into patient financing that lenders do not. Like, what they look for, the Pros & Cons of their payment plans, how and when to use a co-signer, and how to be more attractive to lenders. Our primary objective is to help you secure credit, and we can even refer you to lending sources outside the standard patient financing network.

We are here to help

Based on the information we collect from patients, and our knowledge of how financing works, AcQuired determines which credit issuer(s) offer the best chance for approval, and then functions as the patient's agent to help them apply. We also stay current with interest rates and payment plans of credit issuers, and we sincerely welcome the opportunity to discuss their relative Pros & Cons, to allow patients to make a more informed decision.