SORRISO PATIENT FILE

‫ﻣﻠﻒ اﻟﻤﺮﻳﺾ‬ PATIENT FILE File number:

A00001

‫‪PATIENT FILE‬‬

‫‪english missing data xxxxxxxxxxxxxxxxxxxxxxxxxx‬‬ ‫ﻧﺮﺟﻮ ﻣﻨﻜﻢ ﻣﻠﺊ اﻟﺒﻴﺎﻧﺎت اﻻﺗﻴﺔ ﺑﻌﻨﺎﻳﺔ و اﻻﻣﻀﺎء ﻓﻲ ﻧﻬﺎﻳﺔ اﻟﺼﻔﺤﺔ ﻟﻼﻫﻤﻴﺔ‬

‫اﻟﺒﻴﺎﻧﺎت اﻟﺸﺨﺼﻴﺔ‬

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‫‪Date:‬‬

‫‪Personal Data‬‬ ‫اﻟﻤﻬﻨﺔ‬ ‫‪Occupation‬‬

‫اﻻﺳﻢ ﺑﺎﻟﻜﺎﻣﻞ‬ ‫‪Full Name‬‬ ‫اﻟﻌﻤﺮ‬ ‫‪Age‬‬

‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬ ‫‪Date of birth‬‬

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‫اﻟﻌﻨﻮان‬ ‫‪Address‬‬

‫اﻟﺠﻨﺲ‬ ‫‪Sex‬‬

‫رﻗﻢ اﻟﻤﻮﺑﺎﻳﻞ‬ ‫‪Mobile‬‬

‫اﻟﺠﻨﺴﻴﺔ‬ ‫‪Nationality‬‬

‫اﻟﺒﺮﻳﺪ اﻻﻟﻜﺘﺮوﻧﻲ‬ ‫‪E-mail‬‬

‫ﻛﻴﻒ ﺗﻌﺮﻓﺖ ﻋﻠﻲ اﻟﻌﻴﺎدة‬ ‫اﺻﺪﻗﺎء‬ ‫‪Friends‬‬ ‫اﻟﻌﺎﺋﻠﺔ‬ ‫‪Family‬‬

‫ﺗﺤﻮﻳﻞ ﻣﻦ‬ ‫دﻛﺘﻮر اﺧﺮ‬ ‫‪Referal‬‬ ‫ﺗﻌﺎﻗﺪات‬ ‫‪Insurance‬‬

‫‪How did you know The clinic‬‬

‫ﻓﻴﺴﺒﻮك‬ ‫‪Facebook‬‬

‫ﺟﻮﺟﻞ‬ ‫‪GOOGLE‬‬

‫اﻧﺴﺘﺠﺮام‬ ‫‪Instagram‬‬

‫ﻓﻴﺰﻳﺘﺎ‬ ‫‪VERZEETA‬‬

‫اﻟﺒﻴﺎﻧﺎت اﻟﻄﺒﻴﺔ‬ ‫ﻫﻞ ﺗﻌﺎﻧﻲ او ﻋﺎﻧﻴﺖ ﻓﻲ ﻓﺘﺮة ﻣﺎ اي ﻣﻦ ﻫﺬة اﻟﻤﺸﺎﻛﻞ اﻟﺼﺤﻴﺔ‬ ‫ﺿﻊ ﻋﻼﻣﺔ ﻓﻲ اﻟﺪاﺋﺮة اﻣﺎم ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ ﻋﻠﻴﻚ‬

‫‪Medical Data‬‬ ‫اذا ﻛﻨﺖ ﺗﻌﺎﻧﻲ ﻣﻦ اﻟﺤﺴﺎﺳﻴﺔ ﺿﺪ اﺣﺪ اﻟﻌﻮاﻣﻞ اﻟﺘﺎﻟﻴﺔ ﻧﺮﺟﻮ وﺿﻊ ﻋﻼﻣﺔ‬ ‫‪Missing english data xxxxxxxxxxxxxxxxxxxxxxxx‬‬

‫‪english missing data xxxxxxxxxxxxxxxxxxxxxxxxxx‬‬ ‫ﻣﺸﺎﻛﻞ واﻣﺮاض اﻟﺪم‬ ‫‪Blood Diseases‬‬

‫ﻣﺮض اﻟﺴﻜﺮي‬ ‫‪Diabetes‬‬

‫ﻧﻘﻞ دم‬ ‫‪Blood Transfusion‬‬

‫ﻣﺸﺎﻛﻞ ﻋﺼﺒﻴﺔ‬ ‫ﻣﺜﻞ اﻟﺼﺮع وﻏﻴﺮه‬ ‫‪Nervous problems‬‬ ‫‪such as epilepsy‬‬

‫اﻟﻤﻬﺪﺋﺎت واﻟﺤﺒﻮب اﻟﻤﻨﻮﻣﺔ‬ ‫& ‪Tranquilizers‬‬ ‫‪sleeping pills‬‬

‫ﻣﺸﺎﻛﻞ اﻟﻐﺪة اﻟﺪرﻗﻴﺔ‬ ‫‪Thyroid problems‬‬

‫اﻻﺳﺒﺮﻳﻦ‬ ‫‪Aspirin‬‬

‫ﻣﺸﺎﻛﻞ ﻗﻠﺒﻴﺔ‬ ‫‪Heart problems‬‬ ‫ﺳﻜﺘﺔ ﻗﻠﺒﻴﺔ ﺳﺎﺑﻘﺔ‬ ‫‪Previous heart attack‬‬ ‫ﻣﺪﺧﻦ ﻟﻠﺴﺠﺎﺋﺮ او اﻟﺸﻴﺸﺔ‬ ‫‪smoker of cigarettes‬‬ ‫‪or hookah‬‬ ‫ﺻﻤﺎﻣﺎت او ﻣﻔﺎﺻﻞ ﺻﻨﺎﻋﻴﺔ‬ ‫‪Industrial Valves or Joints‬‬ ‫ﻣﺸﺎﻛﻞ رﺋﻮﻳﺔ‬ ‫‪lung problems‬‬ ‫ﻣﺸﺎﻛﻞ اﻟﻜﻠﻰ‬ ‫‪Kidney problems‬‬ ‫ﻣﺸﺎﻛﻞ او اﻟﺘﻬﺎﺑﺎت اﻟﻜﺒﺪ‬ ‫‪Liver problems or infection‬‬

‫اﻟﺘﻬﺎﺑﺎت اﻟﻤﻔﺎﺻﻞ‬ ‫‪Arthritis‬‬ ‫ﻃﻔﺢ ﺟﻠﺪي ‪ /‬ﻣﺸﺎﻛﻞ‬ ‫اﻟﺘﺠﻠﻂ )ﺳﻴﻮﻟﺔ اﻟﺪم(‬ ‫‪Rash‬‬

‫اﺧﺮي‬ ‫‪Other‬‬

‫اﻟﺘﺨﺪﻳﺮ‪ /‬اﻟﺒﻨﺞ اﻟﻤﻮﺿﻌﻲ‬ ‫‪Anesthesia /‬‬ ‫‪local anesthesia‬‬

‫ﻣﺎدة اﻻﺗﻜﺲ‬ ‫‪LATEX‬‬ ‫اﻟﺒﻨﺴﻠﻴﻦ او ﻏﻴﺮه ﻣﻦ اﻟﻤﻀﺎدات‬ ‫اﻟﺤﻴﻮﻳﺔ اﺧﺮى ؟‬ ‫?‪Penicillin or other antibiotics‬‬

‫اذا ﻛﻨﺖ ﺗﺘﻨﺎول ادوﻳﺔ ﻓﻲ اﻟﻮﻗﺖ اﻟﺤﺎﻟﻴﺎو ادوﻳﺔ ﺑﺼﻔﺔ ﻣﺴﺘﻤﺮة ﻳﺮﺟﻰ ﻛﺘﺎﺑﺘﻬﺎ ﻫﻨﺎ‬ ‫‪If you are currently taking medication or medication on an ongoing‬‬ ‫‪basis, please write them down here‬‬

‫ﻧﺰﻳﻒ ﺷﺪﻳﺪ ﺑﻌﺪ ﻋﻤﻠﻴﺔ ﺟﺮاﺣﻴﺔ‬ ‫‪Blood thinning‬‬ ‫ﺳﺮﻃﺎﻧﺎت او اورام‬ ‫‪cancer or tumors‬‬ ‫ﻣﺸﺎﻛﻞ اﻟﺠﻴﻮب اﻻﻧﻔﻴﺔ‬ ‫اﻟﺤﺴﺎﺳﻴﺎت واﻻزﻣﺔ اﻟﺼﺪرﻳﺔ‬ ‫‪Sinus Problems Allergies‬‬ ‫‪such as asthma & chest pain‬‬

‫‪Sorriso ezmerli‬‬

PATIENT FILE

MISSING ENGLISHxxxxx

‫اﻟﺒﻴﺎﻧﺎت اﻟﺨﺎﺻﺔ ﺑﺎﻟﻔﻢ و اﻻﺳﻨﺎن‬ : ‫ﻧﺮﺟﻮ ﻛﺘﺎﺑﺔ اﻟﺸﻜﻮى اﻟﺮﺋﻴﺴﻴﺔ ﻫﻨﺎ‬ Please write the main complaint here

‫ﻫﻞ اﻧﺖ راض ﻋﻦ ﺟﻤﺎل اﺳﻨﺎﻧﻚ ﻣﻦ ﺣﻴﺚ اﻟﻠﻮن و اﻟﺘﺮﺗﻴﺐ و ﺷﻜﻞ‬ ‫اﻻﺑﺘﺴﺎﻣﺔ ؟‬ Are you satisfied with the beauty of your teeth in terms of color, arrangement and smile shape? ‫ ﻓﻤﺎ ﻫﻮ ؟‬, ‫إن ﻛﻨﺖ ﺗﺮى أن ﻫﻨﺎك ﻣﺎ ﻳﻤﻜﻦ ﺗﻐﻴﻴﺮه ﻟﻼﻓﻀﻞ‬ If you think there is something that can be changed for the better, what is it?

‫ﻫﻞ ﻟﺪﻳﻚ ﻋﺎدات ﻛﺎﻟﻌﺾ ﻋﻠﻰ اﻻﻇﺎﻓﺮ او اﻻﻗﻼم ؟‬ Do you have habits such as biting nails or pens? ‫ﻫﻞ ﺗﻘﻮم ﺑﺎﻟﻌﺾ اﻟﻼإرادي ) اﻟﺠﺰ ( ﻋﻠﻰ اﻻﺳﻨﺎن اﺛﻨﺎء اﻟﻨﻮم او ﺧﻼل‬ ‫اﻟﻴﻮم ؟‬ Do you involuntary biting (mowing) on the teeth during sleep or during the day?

‫ﻫﻞ ﺗﺸﻌﺮ ﺑﺎي ﺣﺮﻛﺔ او آﻻم ﻏﻴﺮ ﻃﺒﻴﻌﻴﺔ ﻓﻲ ﻣﻔﺼﻞ اﻟﻔﻚ ؟‬ Do you feel any abnormal movement or pain in the jaw joint? ‫اﺳﺌﻠﺔ ﺧﺎﺻﺔ ﺑﺎﻟﺴﻴﺪات‬ Question for Women ‫ﻫﻞ اﻧﺖ ﺣﺎﻣﻞ ﺑﺸﻜﻞ ﻣﺆﻛﺪ او ﺗﺘﻮﻗﻌﻴﻦ ﻣﻮﻟﻮدا ﻓﻲ اﻟﻮﻗﺖ اﻟﺤﺎﻟﻲ ؟‬ Are you definitely pregnant or expecting a baby at the moment? ‫ﻓﻲ اي ﺷﻬﺮ ﻣﻦ اﻟﺤﻤﻞ‬, ‫اذا ﻛﺎﻧﺖ اﻻﺟﺎﺑﺔ ﻧﻌﻢ‬ If the answer is yes, in which month of pregnancy

‫ﻫﻞ ﺗﺸﻌﺮ ﺑﺄي ﺣﺮﻛﺔ )ﻟﺨﻠﺨﺔ ( او ﻋﺪم ﺛﺒﺎت اي ﻣﻦ اﺳﻨﺎﻧﻚ ؟‬ Do you feel any movement (looseness) or instability of any of your teeth? ‫ﻫﻞ ﻳﺤﺪث اي ﻧﺰﻳﻒ ﻓﻲ اﻟﻠﺜﺔ ﻋﻨﺪﻣﺎ ﺗﻘﻮم ﺑﻐﺴﻞ اﺳﻨﺎﻧﻚ ؟‬ Do any bleeding occur in the gums when you brush your teeth? ‫ﻫﻞ ﻟﺪﻳﻚ اي اﺳﻨﺎن ﻣﻔﻘﻮدة ﺗﺮﻏﺐ ﻓﻲ ﺗﻌﻮﻳﻀﻬﺎ ؟‬ Do you have any missing teeth that you would like to replace?

Appoiment Policy

‫ﺳﻴﺎﺳﺔ اﻟﻤﻮاﻋﻴﺪ‬

‫ ﺳﺎﻋﺔ ﻋﻠﻰ اﻻﻗﻞ ﻟﻜﻲ‬24 ‫ ﻓﻲ ﺣﺎﻟﺔ ﺗﻐﻴﻴﺮ او اﻟﻐﺎء اﻟﻤﻮﻋﺪ اﻟﻤﺤﺪد ﻣﺴﺒﻘﺎ ﻣﻊ ﻓﺮﻳﻖ اﻟﻌﻴﺎدة ﻳﺮﺟﻰ اﻻﺧﻄﺎر ﻣﺴﺒﻘﺎ ب‬‫ ﻳﺘﻢ اﺗﺨﺎذ اﻻﺟﺮآت اﻟﻼزﻣﺔ‬‫ دﻗﻴﻘﺔ‬30 ‫ ﻓﻲ ﺑﻌﺾ اﻟﺤﺎﻻت ﻫﻨﺎك زﻣﻦ ﻣﺘﻮﻗﻊ ﻟﻼﻧﺘﻈﺎر ﻻ ﻳﺰﻳﺪ ﻋﻦ‬‫ﻧﺮﺟﻮ اﻇﻬﺎر اﺛﺒﺎت ﺷﺨﺼﻴﺔ ﻟﻔﺮﻳﻖ اﻟﻌﻤﻞ و ذﻟﻚ ﻻﻋﺪاد ﻣﻠﻒ اﻟﻜﺘﺮوﻧﻲ ﻟﻜﻢ‬

@Sorisso Ezmerli

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In the event of changing or canceling the previously scheduled appointment with the clinic team, please notify at least 24 hours in advance to take the necessary measures.

In some cases, an expected time of not more than 30 minutes.

Please show proof of identity for the work team in order to prepare an electronic file for you.

‫اﻟﺘﺎرﻳﺦ‬ Date

Sorriso ezmerli

‫اﻻﻣﻀﺎء‬ Signature

PATIENT FILE

clinic policy

‫ﺳﻴﺎﺳﺔ اﻟﻌﻴﺎدة‬

Engliesh missed xxxxxxxxxxxxxxxxxxxxxxxxxx

(‫)ﺑﺮﺟﺎء ﻗﺮأﺗﻬﺎ ﺑﻌﻨﺎﻳﺔ واﻟﺘﻮﻗﻴﻊ ﺑﺎﻻﺳﻔﻞ ﻋﻠﻲ اﻟﻤﻮاﻓﻘﺔ‬

‫اﻟﻘﻮاﻋﺪ اﻟﻌﺎﻣﺔ‬

General Rules Show your identity card / passport to prepare a special electronic file for you.

‫ ﺟﻮاز ﺳﻔﺮ ﻹﻋﺪاد ﻣﻠﻒ اﻟﻴﻜﺘﺮوﻧﻲ ﺧﺎص ﻟﻜﻢ‬/ ‫اﻇﻬﺎر ﺑﻄﺎﻗﺔ ﺗﺤﻘﻴﻖ اﻟﺸﺨﺼﻴﺔ‬

All patients and their families are informed of the cost of the medical service required to be provided to them before starting it.

‫ﺟﻤﻴﻊ اﻟﻤﺮﺿﻲ ﻣﺴﺌﻮﻟﻴﻦ ﻋﻦ دﻓﻊ ﺗﻜﻠﻔﺔ ﺧﺪﻣﺎﺗﻬﻢ اﻟﻄﺒﻴﺔ اﻟﻤﻘﺪﻣﺔ‬ ‫ﻛﻞ اﻟﻤﺮﺿﻲ وﻋﺎﺋﻼﺗﻬﻢ ﻳﺘﻢ اﻋﻼﻣﻬﻢ ﺑﺘﻜﻠﻔﺔ اﻟﺨﺪﻣﺔ اﻟﻄﺒﻴﺔ اﻟﻤﻄﻠﻮب ﺗﻘﺪﻳﻤﻬﺎ ﻟﻬﻢ‬ ‫ﻗﺒﻞ اﻟﺒﺪء ﻓﻴﻬﺎ ﺟﻤﻴﻊ اﻟﻤﺮﺿﻲ ﻣﺴﺌﻮﻟﻴﻦ ﻋﻦ دﻓﻊ ﺗﻜﻠﻔﺔ ﺧﺪﻣﺎﺗﻬﻢ اﻟﻄﺒﻴﺔ اﻟﻤﻘﺪﻣﺔ‬

All patients are responsible for paying the cost of their medical services provided.

The full value or part of the cost of the service provided is paid during the day's session.

Patients who have insurance or another entity that pays for them as a result of their contract, are obligated to pay in the event that the other entity fails to pay.

The clinic provides different payment methods, which are as follows

‫ﻳﺘﻢ دﻓﻊ ﻛﺎﻣﻞ ﻗﻴﻤﺔ او ﺟﺰء ﻣﻦ ﺗﻜﻠﻔﺔ اﻟﺨﺪﻣﺔ اﻟﻤﻘﺪﻣﺔ ﺧﻼل ﺟﻠﺴﺔ اﻟﻴﻮم‬ ، ‫اﻟﻤﺮﺿﻲ اﻟﺬﻳﻦ ﻟﺪﻳﻬﻢ ﺗﺄﻣﻴﻦ او ﺟﻬﻪ اﺧﺮي ﺗﻘﻮم ﺑﺎﻟﺪﻓﻊ ﻋﻨﻬﻢ ﻧﺘﻴﺠﺔ ﻟﺘﻌﺎﻗﺪﻫﻢ‬ ‫ﻣﻠﺰﻣﻴﻦ ﺑﺎﻟﺪﻓﻊ ﻓﻲ ﺣﺎﻟﺔ ﺗﺨﻠﻒ اﻟﺠﻬﻪ اﻻﺧﺮي ﻋﻦ اﻟﺪﻓﻊ‬

‫ﺗﻮﻓﺮ اﻟﻌﻴﺎدة ﻃﺮق ﻣﺨﺘﻠﻔﺔ ﻟﻠﺪﻓﻊ ﺗﺘﻤﺜﻞ ﻓﻲ اﻻﺗﻲ‬

6 . 7 ! 8 % 5 - ! ' ! 3Payment 5 8 by>cash! & . 5 * 3 ? ! ( & 1 " @ ! , . # ! ( 8 = * ! 5 > ! ) . / ' ! 6 $ ‫اﻟﻨﻘﺪي‬ 3 ‫اﻟﺪﻓﻊ‬ A ! B ‫اﻟﺪﻓﻊ ﻋﻦ ﻃﺮﻳﻖ اﻟﻔﻴﺰ‬ # Payment ! in Visa J %payment " B K % ! ( & # ! $ / % 4 ! ( & 5 * 3 ? ! , . # ! ( &‫اﻟﻤﺘﻌﺪدة‬ 5 . ‫اﻟﺪﻓﻊ‬ L ‫ﺗﻄﺒﻴﻘﺎت‬ ! ( ‫ﻃﺮﻳﻖ‬ 9 & 8 B ‫ااﻟﺪﻓﻊ‬ * 0 M ‫اﻟﻜﺘﺮوﻧﻲ ﻋﻦ‬ through multiple payment applications B O P # ! Q R ( ! ( & 5 6 . 7 The installment system is to choose the appropriate payment plan provided by the clinic to the patient

‫ﻧﻈﺎم اﻟﺘﻘﺴﻴﻂ ﺑﻴﺘﻢ اﺧﺘﻴﺎر ﺧﻄﺔ اﻟﺪﻓﻊ اﻟﻤﻨﺎﺳﺒﺔ اﻟﺘﻲ ﺗﻮﻓﺮﻫﺎ‬ ‫اﻟﻌﻴﺎدة ﻟﻠﻤﺮﻳﺾ‬ ‫ﻛﻴﻔﻴﺔ ﺳﺪاد ﻗﻴﻤﺔ اﻟﺨﺪﻣﺔ‬

How to pay for the service Treatment procedures in one session must be pay it in full.

‫ﻓﻲ ﺣﺎﻟﺔ اﺟﺮاء ﻋﻼﺟﻲ ﻓﻲ ﺟﻠﺴﺔ واﺣﺪة ﻳﺠﺐ ﺳﺪاد اﻟﻤﺒﻠﻎ ﻛﺎﻣﻼ‬

In the case of the procedure distributed over more than one session, the patient can pay for more than one session, so that the first payment is 50% and the rest of the treatment remains with the last session of the procedure.

‫ﻓﻲ ﺣﺎﻟﺔ اﻻﺟﺮاء اﻟﻌﻼﺟﻲ اﻟﻤﻮزع ﻋﻠﻲ اﻛﺜﺮ ﻣﻦ ﺟﺎﻟﺴﺔ ﻳﻤﻜﻦ ﻟﻠﻤﺮﻳﺾ‬ ‫ و ﻳﺘﻢ ﺳﺪاد ﺑﺎﻗﻲ‬٪٥٠ ‫اﻟﺪﻓﻊ ﻋﻠﻲ اﻛﺜﺮ ﻣﻦ ﺟﻠﺴﺔ ﺑﺤﻴﺚ ﺗﻜﻮن اول دﻓﻌﺔ‬ ‫اﻟﻤﺒﻠﻎ ﻣﻊ اﺧﺮ ﺟﻠﺴﺔ ﻟﻼﺟﺮاء اﻟﻌﻼﺟﻲ‬

In the case of in case you pay a deposit or payment on account, it is added to the patient’s electronic file, and the value of each service is deducted from all services that cover this amount.

‫ﻓﻲ ﺣﺎﻟﺔ اﻟﺪﻓﻊ ﻣﻘﺪﻣﺎ او دﻓﻌﺔ ﺗﺤﺖ اﻟﺤﺴﺎب ﻳﺘﻢ اﺿﺎﻓﺘﻬﺎ اﻟﻲ ﺣﺴﺎب‬ ‫اﻟﻤﺮﻳﺾ ﻋﻠﻲ اﻟﻤﻠﻒ اﻻﻟﻜﺘﺮوﻧﻲ وﺑﻴﺘﻢ ﺧﺼﻢ ﻗﻴﻤﺔ ﻛﻞ ﺧﺪﻣﺔ وﺗﻮزﻳﻌﻬﺎ‬ ‫ﻋﻠﻲ ﻛﺎﻓﺔ اﻟﺨﺪﻣﺎت اﻟﺘﻲ ﺗﻐﻄﻲ ﻫﺬا اﻟﻤﺒﻠﻎ‬

Rehabilitation and Complex case or long-term treatment plan the case of a large treatment plan, the amount is divided into payments over the length of the treatment period. 50% is paid in advance - 30% during the treatment period - 20% at the end of the treatment period and it is recorded in the payment agreement with an explanation of its dates, and it is signed by the patient and kept in his financial file In this case, all patients must sign a payment agreement for financial dues

‫اﻟﺘﺎرﻳﺦ‬ Date

Sorriso ezmerli

‫ﺧﻄﺔ اﻟﻌﻼﺟﻴﺔ اﻟﻄﻮﻳﻠﺔ‬ ‫ﻓﻲ ﺣﺎﻟﺔ اﻟﺨﻄﺔ اﻟﻌﻼﺟﻴﺔ اﻟﻜﺒﻴﺮة ﻳﺘﻢ ﺗﻘﺴﻴﻢ اﻟﻤﺒﻠﻎ اﻟﻲ دﻓﻌﺎت ﻋﻠﻰ ﻃﻮل ﻓﺘﺮة‬ ‫ﻣﻊ اﻧﺘﻬﺎء ﻓﺘﺮة اﻟﻌﻼج واﺛﺒﺎﺗﻬﺎ ﻓﻲ‬٪٢٠ ‫ ﺧﻼل ﻓﺘﺮة اﻟﻌﻼج‬٪٣٠ ‫ ﺗﺪﻓﻊ ﻣﻘﺪﻣﺎ‬٪٥٠‫اﻟﻌﻼج‬ ‫اﺗﻔﺎﻗﻴﺔ اﻟﺴﺪاد ﻣﻊ ﺗﻮﺿﻴﺢ ﻣﻮاﻋﻴﺪﻫﺎ وﻳﺘﻢ ﺗﻮﻗﻴﻌﻬﺎ ﻣﻦ ﻗﺒﻞ اﻟﻤﺮﻳﺾ واﻻﺣﺘﻔﺎظ ﺑﻬﺎ‬ ‫ﻓﻲ ﻣﻠﻔﻪ اﻟﻤﺎﻟﻲ‬ ‫وﻓﻲ ﻫﺬه اﻟﺤﺎﻟﺔ ﻋﻠﻲ ﺟﻤﻴﻊ اﻟﻤﺮﺿﻲ ﺗﻮﻗﻴﻊ اﺗﻔﺎﻗﻴﺔ ﺳﺪاد ﻟﻠﻤﺴﺘﺤﻘﺎت اﻟﻤﺎﻟﻴﺔ‬ ‫ﻧﻈﺎم اﻟﺘﻘﺴﻴﻂ ﺑﻴﺘﻢ اﺧﺘﻴﺎر ﺧﻄﺔ اﻟﺪﻓﻊ اﻟﻤﻨﺎﺳﺒﺔ اﻟﺘﻲ ﺗﻮﻓﺮﻫﺎ اﻟﻌﻴﺎدة ﻟﻠﻤﺮﻳﺾ‬

‫اﻻﻣﻀﺎء‬ Signature