Note: Fields followed by an asterisk (*) are required.

Choose a branch for the financing request

Credit requirement (quote)

Supplier’s name

Term requested

Equipment ($)

Computers ($)

Furniture ($)

Office furnishings ($)

Leasehold improvements ($)

Others ($)


Company Information

Legal name of the company

Practitioner’s name*

Company address



Postal code

Commercial phone number*




Time remaining on lease

Gross monthly payments

Monthly expenditures

Personal information

Date of birth


Year you graduated from university

Number of years in private practice

Home address



Postal code

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?

Are you involved in a lawsuit or claim?

Do you have an outstanding tax balance (income, property, or corporate tax, GST, QST)?

  • The undersigned certifies that the information above is complete and accurate.
  • Note: You are not required to provide your SIN, but it could help us perform a credit check.

Additional comments

Consent concerning personal information*

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.