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https://mydoctor.co.il/wp-admin/admin-ajax.php

https://mydoctor.co.il/avitzah-כיסוי-לטיפולי-שיניים

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Enter your primary subscription information

Date of birth*

* Marital status

--- Select ---SingleMarried/MarriedDivorcedWidower

* HMO

--- Select ---GeneralMaccabiUnifiedNational

*I would like to join the subscription writer

.

Dental Plus

.

כיסוי לשיניים (כולל אורתודנטיה) - דנטל גולד

.

Aesthetic Treatments - Beauty +

*The details of the subscriber are identical to the details of the credit card

.

yes

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not

Add family members

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To add a child click here

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To add a spouse click here

*How many children do you want to add

.

1

.

2

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3

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4

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5

*Full name - Spouse

* ID - Spouse

* Date of Birth - Spouse

*I would like to attach to the subscription letter - a spouse

.

Dental Plus

* Full name - 1 family member

* ID card - 1 family member

* Date of birth - 1 family member

*I would like to attach to the subscription letter - 1 family member

.

דנטל גולד (כיסוי שיניים לילד בלבד כולל יישור שיניים)

* Full Name - Family Member 2

* ID - Family member 2

* Date of birth - 2 family members

*I would like to attach to the subscription letter - a family member 2

.

דנטל גולד (כיסוי שיניים לילד בלבד כולל יישור שיניים)

* Full name - Family member 3

* ID - Family member 3

* Date of birth - 3 family member

*I would like to attach to the subscription letter - a family member 3

.

דנטל גולד (כיסוי שיניים לילד בלבד כולל יישור שיניים)

* Full Name - Family Member 4

* ID card - family member 4

* Date of Birth - Family Member 4

*I would like to attach to the subscription letter - a family member 4

.

דנטל גולד (כיסוי שיניים לילד בלבד כולל יישור שיניים)

* Full Name - Family Member 5

* ID - Family member 5

* Date of Birth - Family Member 5

*I would like to attach to the subscription letter - a family member 5

.

דנטל גולד (כיסוי שיניים לילד בלבד כולל יישור שיניים)

*consent

.

I, the undersigned, hereby confirm that I have accepted all the terms of the subscription letter and I hereby authorize the charge to the credit card whose details appear above. This voucher was signed by me without specifying the number of payments and their amounts, since it was given by authorizing "My Doctor" to transfer to the card issuer charges from time to time as specified to the issuer, this authorization will expire upon notice to the supplier. I hereby confirm that all the details are true and correct in my signature on joining the service, I confirm that I have received the subscription letter as well as full disclosure, as well as the monthly premium payment and the terms of the subscription letter

Signature

send