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  Signature & Approval

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Enter your primary subscription information

Date of birth*

* Male / Female

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* Marital status

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* HMO

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* There is a supplementary HMO

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*I would like to join the subscription writer

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דנטל

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Private Medicine

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ביוטי

* I want to add more family members

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

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*How many family members do you want to add

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* ID card - 1 family member

* Date of birth - 1 family member

* Male / Female - 1 Family Member

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* HMO - 1 family member

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* There is a supplementary HMO - 1 family member

--- Select ---yesnotI don't know

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

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Dental+ (Dental Cover)

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Dental Gold (Dental Cover Including Pediatric Orthodontics)

* Full Name - Family Member 2

* ID - Family member 2

* Date of birth - 2 family members

* Male / Female - 2 family members

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* Health Fund - Family Member 2

--- Select ---GeneralMaccabiUnifiedNational

* There is a supplementary HMO - a family member 2

--- Select ---yesnotI don't know

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

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Dental+ (Dental Cover)

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Dental Gold (Dental Cover Including Pediatric Orthodontics)

* Full name - Family member 3

* ID - Family member 3

* Date of birth - 3 family member

* Male / Female - Family Member 3

--- Select ---male Female

* Health Fund - Family Member 3

--- Select ---GeneralMaccabiUnifiedNational

* There is a supplementary HMO - family member 3

--- Select ---yesnotI don't know

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

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Dental+ (Dental Cover)

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Dental Gold (Dental Cover Including Pediatric Orthodontics)

* Full Name - Family Member 4

* ID card - family member 4

* Date of Birth - Family Member 4

* Male / Female - Family Member 4

--- Select ---male Female

* Health Fund - Family Member 4

--- Select ---GeneralMaccabiUnifiedNational

* There is a supplementary HMO - family member 4

--- Select ---yesnotI don't know

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

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Dental+ (Dental Cover)

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Dental Gold (Dental Cover Including Pediatric Orthodontics)

* Full Name - Family Member 5

* ID - Family member 5

* Date of Birth - Family Member 5

* Male / Female - Family Member 5

--- Select ---male Female

* Health Fund - Family Member 5

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* There is a supplementary HMO - a family member 5

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Dental+ (Dental Cover)

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Dental Gold (Dental Cover Including Pediatric Orthodontics)

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*consent

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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

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