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/hospital Details of operation: Principal member Patient Group (if on a company plan) Section A Payment by Electronic Funds Transfer to a bank account Bank name: Details of medication: SWIFT / BIC code:* Sort code (UK only): - - Dental treatment Account number: Annual check Preventive Major restorative Orthodontics FULL IBAN NUMBER:* Account name / payee: Accident / emergency treatment Currency for the transfer: Details of treatment: Bank address: Hospital dates: Admission.

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