מִי שֶׁבֵּרַךְ אֲבוֹתֵינוּ אַבְרָהָם יִצְחָק וְיַעֲקב, משֶׁה וְאַהֲרוֹן, דָּוִד וּשְׁלמה, הוּא יְבָרֵךְ אֶת הַחוֹלֶה/החולה [שֵׁם הַחוֹלֶה]. הַקָּדוֹשׁ בָּרוּך הוּא יִמָּלֵא רַחֲמִים עָלָיו/עליה לְהַחֲלִימו/החלימה וּלְרַפְּאוֹתו/רפאותה, לְהַחֲזִיקו/החזיקה וּלְהַחֲיוֹתו/החיותה, וִישַׁלַּח לו/לה שְׁלוּחָה מְהֵרָה לְתוֹךְ קִרְבּוֹ/קרבה, שְׁלוּחָה חֲלוּטָה לְתוֹךְ מֵעָיו/מעיה, בְּתוֹךְ שְׁאָר חוֹלֵי יִשְׂרָאֵל, בְּתוֹךְ שְׁאָר חוֹלֵי יִשְׂרָאֵל, שֶׁבָּזְּכוּת זִכְיוֹן הָרַבִּים דְּשָׁפִיר עֲלֵיהוֹן יְהוָה נָא רְפָא נָא לָהוֹ:
May He who blessed our fathers, Abraham, Isaac and Jacob, Moses and Aaron, David and Solomon, heal (sick person's Hebrew name and that of his mother), because (Hebrew name of the person who pledged charity for the sake of the sick person and that of his/her father) pledged charity, without a vow, for his sake. In this merit may the Holy One, blessed be He, be filled with mercy for him, to restore him to health and to cure him, to strengthen him and to invigorate him. And may He hasten to send him from heaven a complete recovery to his two hundred and forty-eight bodily parts and three hundred and sixty-five veins, among the other sick people of Israel, a healing of spirit and a healing of body; and let us say, Amen.