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APPLICATION FORM Date: _________________ First Name Middle Name Last Name Birth Date Status Address Referred By: ________________ : _______________________________________________________ : _______________________________________________________ : _______________________________________________________ : ___________________ Age:__________Sex:________________ : _______________________ Contact No: __________________ : ________________________________________________________ ________________________________________________________ BENEFICIARY First Name : _______________________________________________________ Middle Name : _______________________________________________________ Last Name : _______________________________________________________ Relationship : ____________________ Contact No. :____________________ Birth Date : ____________________ Age: _________ Sex: ______________ APPLICATION FORM Date: _________________ Referred By: ________________ First Name : _______________________________________________________ Middle Name : _______________________________________________________ Last Name : _______________________________________________________ Birth Date Status Address : ___________________ Age:__________Sex:________________ : _______________________ Contact No: __________________ : ________________________________________________________ ________________________________________________________ BENEFICIARY First Name : _______________________________________________________ Middle Name : _______________________________________________________ Last Name : _______________________________________________________ Relationship : ____________________ Contact No. :____________________ Birth Date : ____________________ Age: _________ Sex: ______________ I fully understood the product/plan as presented and hereby confirm and acceptance affixing my signature below. I fully understood the product/plan as presented and hereby confirm and acceptance affixing my signature below. SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME REMINDER: REMINDER: Please set an appointment first with our accredited dentist before any consultations. All dental check ups and services indicates in the plans will be considered free or have discounts, otherwise, the cardholder is oblige to pay the services rendered given by our affiliated dentists. This card is valid for one (1) year from the date of the card enrolled. Please set an appointment first with our accredited dentist before any consultations. All dental check ups and services indicates in the plans Benefit will be considered free or have discounts, otherwise, the cardholder is oblige to pay the services rendered given by our affiliated dentists. This card is valid for one (1) year from the date of the card enrolled. FOR CASHIER USE ONLY: Account Manager: ______________________________________________ Contact Person: ________________________Position:________________ PIS OR No. : _____________________Date:____________________________ PIS Name: _____________________________Branch:___________________ HEAD OFFICE: Rm. 508 Campos Rueda Bldg. #101 Urban Ave. Brgy. Pio Del Pilar, Makati City FOR CASHIER USE ONLY: Account Manager: ______________________________________________ Contact Person: ________________________Position:________________ PIS OR No. : _____________________Date:____________________________ PIS Name: _____________________________Branch:___________________ HEAD OFFICE: Unit 302-B Villa Development Bldg., Jupiter St., Corner Makati Ave., Makati City For Only 1,400 + 100 Processing fee = P 1,500 HWM Dental Health Card GIVE YOUR 100% Great Smile With benefits as follows: Unlimited Consultations Oral Hygiene Instruction One (1) Oral Prophylaxis per year mild to moderate only Annual Dental Examination Temporary Fillings (maximum of 15 surfaces/year only) Recementation of jacket crown inlays and onlays Unlimited Simple Tooth extraction except surgery for impaction Adjustment of Dentures Orthodontic Consultation Aesthetic Dental Consultation Treatment of Dental related pain excluding cost of prescribed medicines Relief and/or prescription for acute dental pain Treatment for lesions, wounds and burns Emergency desensitization of hypersensitive teeth The member can avail 5 % up to 30% discount for these services: 1. 2. 3. 4. 5. Dentures, jacket crown, braces and other orthodontic appliances Aesthetic procedures (teeth whitening) Rebase/reline/repair/of dentures Surgical removal of impacted tooth Other special dental services With Free Php 50,000 Accidental Death and Disablement Php 25,000 Unprovoked Murders and Assault Php 5,000 Accidental Medical Reimbursement Php 5,000 Accidental Burial Benefits For Only 1,400 + 100 Processing fee = P 1,500 HWM Dental Health Card GIVE YOUR 100% Great Smile With benefits as follows: Unlimited Consultations Oral Hygiene Instruction One (1) Oral Prophylaxis per year mild to moderate only Annual Dental Examination Temporary Fillings (maximum of 15 surfaces/year only) Recementation of jacket crown inlays and onlays Unlimited Simple Tooth extraction except surgery for impaction Adjustment of Dentures Orthodontic Consultation Aesthetic Dental Consultation Treatment of Dental related pain excluding cost of prescribed medicines Relief and/or prescription for acute dental pain Treatment for lesions, wounds and burns Emergency desensitization of hypersensitive teeth The member can avail 5 % up to 30% discount for these services: 1. 2. 3. 4. 5. Dentures, jacket crown, braces and other orthodontic appliances Aesthetic procedures (teeth whitening) Rebase/reline/repair/of dentures Surgical removal of impacted tooth Other special dental services With Free Php 50,000 Accidental Death and Disablement Php 25,000 Unprovoked Murders and Assault Php 5,000 Accidental Medical Reimbursement Php 5,000 Accidental Burial Benefits
