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Start date *
Insurance model * Elite (Without Copayment) Classic (Copayment from 3 €) Plus (Copayment from 6 €) Complet (Copayment from 13 €) DKV Selección (Without copayment) DKV Visa (Without copayment) Reimbursement Elite Reimbursement Classic Reimbursement Premium Reimbursement Plus Reimbursement Complet
Policyholder's date of birth *
DNI/NIE/Passport Policyholder *
Policyholder's nationality *
Address *
Post Code *
Email *
Phone *
Payment period * Monthly Quaterly Biannual Annual
Bank Account *
Date of birth of Insured 1
DNI/NIE/Passport Insured 1
nationality of Insured 1
Height of Insured 1 (cm) *
Weight of Insured 1 (kg) *
1. Has or have had any disease, accident, congenital disorder, hereditary family disease, joint pain, or any other symptoms or pain, or do you have any metabolic pathology (cholesterol, blood pressure, sugar, thyroid)? (Specify answer and year) Insured 1 *
2. Have you received, or are pending to receive any type of surgical, medical, pharmacological, rehabilitation, or dietary treatment (e.g., Diet for Hypertension)? (Specify treatments, causes, and dates) Insured 1. *
3. Have you been hospitalized or undergone surgery, or are you pending hospitalization? (Specify causes and dates) Insured 1 *
4. Have any diagnostic tests been performed on you, or are any pending? (Specify type of test, reason, result, and date) Insured 1 *
Uses glasses. Indicate the diopters for Insured 1 *
Date of birth of Insured 2 *
DNI/NIE/Passport Insured 2 *
nationality of Insured 2 *
Height of Insured 2 (cm) *
Weight of Insured 2 (kg) *
1. Has or have had any disease, accident, congenital disorder, hereditary family disease, joint pain, or any other symptoms or pain, or do you have any metabolic pathology (cholesterol, blood pressure, sugar, thyroid)? (Specify answer and year) Insured 2. *
2. Have you received, or are pending to receive any type of surgical, medical, pharmacological, rehabilitation, or dietary treatment (e.g., Diet for Hypertension)? (Specify treatments, causes, and dates) Insured 2 *
3. Have you been hospitalized or undergone surgery, or are you pending hospitalization? (Specify causes and dates) Insured 2 *
4. Have any diagnostic tests been performed on you, or are any pending? (Specify type of test, reason, result, and date) Insured 2 *
Uses glasses. Indicate the diopters for Insured 2 *
Date of birth of Insured 3 *
DNI/NIE/Passport Insured 3 *
nationality of Insured 3 *
Height of Insured 3 (cm) *
Weight of Insured 3 (kg) *
1. Has or have had any disease, accident, congenital disorder, hereditary family disease, joint pain, or any other symptoms or pain, or do you have any metabolic pathology (cholesterol, blood pressure, sugar, thyroid)? (Specify answer and year) Insured 3 *
2. Have you received, or are pending to receive any type of surgical, medical, pharmacological, rehabilitation, or dietary treatment (e.g., Diet for Hypertension)? (Specify treatments, causes, and dates) Insured 3 *
3. Have you been hospitalized or undergone surgery, or are you pending hospitalization? (Specify causes and dates) Insured 3 *
4. Have any diagnostic tests been performed on you, or are any pending? (Specify type of test, reason, result, and date) Insured 3 *
Uses glasses. Indicate the diopters for Insured 3 *
