Request for a copy of a medical file

St-Elisabeth site - Uccle

02-614 20 00

St-Michel site - Etterbeek

02-614 30 00

Bella Vita Medical Center - Waterloo

02-614 42 00

Personal data (1)

Name

First name

Postal address

Postcode

City

Country

GSM/fixed phone

If this is a request for a complete medical file, please specify :

with blood tests

without blood tests

If this is a request for part of a medical record, please specify:

Nursing record

Medical imaging protocols (X-ray, scintigraphy, ultrasound, scanner, MRI)

Laboratory results

Other examinations

Specify:

Documents to be attached

Copy of both sides of the identity card in pdf format

or a copy of both sides of the identity card in image format

Copy of passport in pdf format

or passport copy in image format

Attorney/Mandate of the trusted person + copy of identity card RECTOVERSO or passport

Designation of legal representative + copy of identity card RECTO-VERSO or passport

Remarks, comments or additional information

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