Equipment Lease Application for Medical Practice

Equipment Lease Application for Medical Practice — Form Fields

This finance template includes 11 fields. Apply to lease diagnostic or treatment equipment for a medical practice or clinic. Free to customize and use on ZenBuild.

• Practice Name (text, required)
• Contact Email (email, required)
• Phone Number (text, required)
• Practice EIN (text, required)
• Practice Type (dropdown selection, required) — options: Primary Care, Dental, Chiropractic, Physical Therapy, Imaging Center, Specialty, Other
• Equipment Description (text, required)
• Equipment Cost ($) (number, required)
• Desired Lease Term (dropdown selection, required) — options: 24 Months, 36 Months, 48 Months, 60 Months, 84 Months
• End-of-Lease Option (dropdown selection, required) — options: Return Equipment, $1 Buyout, 10% Buyout, Fair Market Value Buyout
• Annual Practice Revenue ($) (number, required)
• Years Practice in Operation (number, required)