Financing – Pangi

Completing Your Financing Application

To initiate the process of securing financing for your procedure, please take a moment to complete the Personal Information and Financial & Employment sections below. * Only for patients in the US.

Will you be receiving the care in the US?

Is the applicant below the person receiving the care?

First Name

Last Name

Street

City

State

Zip Code

Date of Birth

Last 4 SSN

Monthly Income

Housing

Housing Monthly Payment

Employment Status

Employer's Name

Employer's Phone Number

Years with Current Employer

Intended Procedure Amount (Optional)

By checking the box below I agree to the following:

Electronic Consent I consent to the following terms, conditions, acknowledgement and disclosoures.

Completing Your Financing Application

info@pangi.com

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