Last Door Recovery Centre - Financing Application Form

323- 8th St., New Westminster, BC V3M 3R3

Fill out our secure online form below or use our printable PDF form that you can complete and fax or mail to us.

Globalsign SSL security certificate

Medicard is Canada's premier medical financing company, and we are proud to be partnered with Last Door Recovery Centre.

Please complete the form below to be one step closer to a new you. Go ahead ... Now you can afford to!


Financing Application Form

Begin the application

* indicates a required field.

You are
     
Your preferred language of communication
   

About You

Salutation
           

Call Before Fax?
     

Current Address


Own or rent?
     

Procedure information


Employment information


Other income

References

Reference #1

Reference #2

Social media handles

Additional information

If you have any further information, or have any questions, please contact us at and we will be happy to assist you.

Terms & conditions