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Start Date *
Insurance Model Elite (Without Copayment) Classic (Copayment from 3 €) Plus (Copayment from 6 €) Complet (Copayment from 12 €) DKV Selección (Without Copago) DKV Visa (Without copayment)
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 *
DNI/NIE/Passport Insured
Date of Birth Insured
Nationality Insured
Weight of the Insured (kg) *
Height of the Insured (cm) *
1. Have you had or do you currently have any illness, accident, congenital condition, hereditary family illness, joint pain, as well as any other symptom or pain, or do you have any metabolic condition (cholesterol, blood pressure, sugar, thyroid)? (Specify response and year) *
2. Have you received, or are you pending to receive any type of surgical, medical, pharmacological, rehabilitative, or dietary treatment (e.g., Hypertensive Diet)? (Specify treatments, causes, and dates) *
3. Have you been hospitalized or undergone surgery, or are you pending hospitalization? (Specify causes and dates) *
4. Have you undergone or are you scheduled to undergo any diagnostic tests? (Specify type of test, reason, result, and date) *
Wears glasses. Please indicate the diopters. *
