Note: Fields followed by an asterisk (*) are required.
Choose a branch for the financing requestMontreal branchToronto branchCalgary branchVancouver branch
Supplier’s name
Term requested
Equipment ($)
Computers ($)
Furniture ($)
Office furnishings ($)
Leasehold improvements ($)
Others ($)
TOTAL ($)
Legal name of the company
Practitioner’s name*
Company address
City
Province
Postal code
Commercial phone number*
Profession*
Email*
OwnerRenter
Time remaining on lease
Gross monthly payments
Monthly expenditures
Date of birth
SIN
Year you graduated from university
Number of years in private practice
Home address
Owner Renter
Number of years at home address
Market value
Balance or mortgage
Monthly payment
Have you ever filed for bankruptcy or lost a lawsuit? YesNo
Are you involved in a lawsuit or claim? YesNo
Do you have an outstanding tax balance (income, property, or corporate tax, GST, QST)? YesNo
Additional comments
By filling out this request, each of the contracting parties (including all lessees and deposits), authorize MediCapital Inc. and its assignee, lender, financing source, representative, or nominee (collectively “we”) to collect, use, hold, and share the personal information you provide or that we collect from you as part of your request and management of your lease (your “personal information”) in order to assess your ability to obtain a lease and remain eligible for it and to assess your current and future ability to fulfil your financial obligations. This use includes continually communicating and sharing your personal information with credit reporting agencies and financial institutions and their representatives or with service providers for the purposes described above in order to prevent and protect both ourselves and you from fraud and to maintain the integrity of the credit system. The use, communication, and sharing of your personal information will continue while your lease or leases are in effect.
