We have received your inquiry, thank you! We will review the request and get back to you as soon as possible

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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 Gold (Dental Cover)

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

yes

not

Add family members

To add a child click here

To add a spouse click here

*How many children do you want to add

1

2

3

4

5

*Full name - Spouse

* ID - Spouse

* Date of Birth - Spouse

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

Dental Gold (Dental Cover)

* 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

Dental Gold (Dental Cover)

* 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

Dental Gold (Dental Cover)

* 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

Dental Gold (Dental Cover)

* 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

Dental Gold (Dental Cover)

* 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

Dental Gold (Dental Cover)

*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