יום מבדקים אורתודונטיה

Personal Information

* First name

* Last Name

* ID

* Phone Number

* E-mail

I agree to receive messages including confirmations, instructions and other messages to the email address and phone number I provided.

payment

600

Payment

Item	Subtotal
Subtotal	Subtotal	₪
Discount
Total	Total	₪

Total Amount

0.00 ₪

* Payment Method

I agree to make out a check

After submitting the form you will be redirected to a secure website to perform the transaction. Only after doing so will your registration be completed.

* Institute Name

* Institute Number

* Institute's accounting contact

* Institute's accounting phone

* Institute's billing address

I agree to make a bank transfer of the aforementioned amount

After submitting the form you will be redirected to PayPal to confirm the transaction. Only after doing so will your registration be completed.

Invitation code

In order to verify that you were invited, please fill in the code you recieved when invited