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Practice financing request

Ready to take the next step in your professional career? Here are two easy ways to get started with Wells Fargo Practice Finance:

Complete the form below to start your application. Your finance specialist will follow up to complete your submission by requesting your social security number and date of birth. (To protect your privacy, we do not collect this information over the Internet.) You will then receive a completed application to sign and return for processing.
Download (.pdf) and send your completed application via mail to:

Wells Fargo Practice Finance
2000 Powell Street, 4th Floor
Emeryville, CA 94608
Or fax it to 1–800–318–8601

Your finance specialist will follow up to answer questions and discuss next steps.

If you have questions about your application or project, please call us at 1–800–326–0376 or contact your regional manager. We look forward to working with you.

NOTE: All applicable fields must be completed for loan consideration.

indicates required field

Personal Information

First Name First Name is required	Last Name Last Name is required
Suffix/Degree	Title Title must be 80 characters or less
Company Company Name is required	Website Website must be 100 characters or less
Email Address Email is required Email must be 100 characters or less Email entered is invalid
Primary Phone Number Phone is required Phone must be 10-digit number Home Office Cell
Secondary Phone Number Home Office Cell
Fax Number Fax must be 10-digit number
Address Home Office
Street Number Street Address is required	City City is required City must be 50 characters or less
State State is required Please select a valid state	Zip Zip code is required Please enter a valid zip code

Other Details

Profession Profession is a required field	License Number
ADA/AAHA/AMA/AOA Member	ADA/AAHA/AOA/ME Number Member number be 10 characters or less
Year Graduated Year graduated be a 4 digit number	Years In Practice
Years Managed a Practice	Business Structure
Interested In Please select from drop down	Financing Timeframe Please select from drop down
Project Amount:
How did you hear about us? Please select from drop down	If Other, please describe: Must be 30 characters or less

What is the best day for us to contact you?	What is the best time to contact you?
Comments Must be 100 characters or less

All practice financing requests are subject to credit approval.

Because we value your privacy, Wells Fargo Practice Finance does not rent, sell or share your personal information except to provide products or services you've requested.

I would prefer not to receive email news and updates on Wells Fargo Practice Finance’s products, services and events.

All practice financing is subject to credit approval. Business Refinance Program is for business term debt only. Revolving credit and existing Wells Fargo Practice Finance debt are not eligible for consolidation.

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