Medical FeePay Patient Application

Your Name

Email Address

Telephone Number

Mobile Number

Application type

Partners or spouses that wish be co-applicants will need to complete the “co-applicant form” available on the Medical FeePay website under the RESOURCES menu.

Practitioner Details

Practitioner Name

Practitioner Suburb

Practitioner State

Estimated Fees

Applicant Details

Applicant 1 Full Name

Date of Brith

Street Address

Suburb

State / Postcode

Marital Status

Number of dependants

Drivers licence number

Are you an Australian Citizen or Permanent Resident?

Are you a current or discharged bankrupt?

What is your residential status?

Length of time at current address

Mortgagor or Landlords name

Monthly mortgage or rental amount

Balance owing on mortgage

Employment Details

Employment status

Occupation

Time in current employment

Monthly take home income

Employers name & contact details (accountant if self employed)

Information about your Vehicle

Vehicle make

Year and Model

Registration number

Is the vehicle financed?

Do you own another vehicle?

Additional vehicle information

Additional Information

Estimated monthly living expenses (excluding mortgage and creditors)

Estimated value of house contents

Creditor Details

Creditor 1 Name

Account Type

Account Limit

Account Balance

Monthly Payment

Creditor 2 Name

Account Type

Account Limit

Account Balance

Monthly Payment

Privacy Release

You give your authorisation to FeePay Funding Pty Ltd and Evergreen Finance Company to seek information about your credit standing and history. You also agree that Evergreen Finance Company may obtain confirmation of your income, employment and residential information, which may be used for the purpose of assessing your application for credit. Evergreen Finance Company reserve the right to confirm and verify any of the information given on this application.

I ACCEPT [I intend my click on this button to be my signature and by clicking I agree to the above statement and its terms]

Submit Application

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