Request for a copy of a medical file

Personal data (1)

Title

Mrs

Mr

Other

Name

First name

Patient's date of birth

GSM/fixed phone

Postal address

N°

Postcode

City

Country

Email

The patient is

Alive

Deceased

Applicant’s identity

Title

Mrs

Mr

Other

Name

First name

Applicant’s date of birth

Phone number

Adress

N°

Postcode

City

Country

Email

Acting as

Patient

Legal representative (Father, mother, guardian)

Beneficiary

Medical expert

Consulting physician

Documents to be attached

Copy of both sides of the identity card in pdf format

Upload requirements

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

Upload requirements

Copy of passport in pdf format

Upload requirements

or passport copy in image format

Upload requirements

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

Upload requirements

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

Upload requirements

Transmission method

Sent by secure email (preferably)

Collection of copies on-site – St-Elisabeth site

Collection of copies on-site – St-Michel site

Copy sent by registered mail to the patient

Copy sent by registered mail to the applicant

Sent to a doctor of your choice (please provide name and address below)

Doctor’s name and address

Request for the complete medical record

I would like to request my complete medical record

Avez-vous consulté un médecin en (cochez la case du service si c’est le cas) :

Ophtalmology Ste-Elisabeth

Ophtalmology St-Michel

Psychiatry Ste-Elisabeth

Psychiatry St-Michel

Dentistry Ste-Elisabeth

Dentistry St-Michel

Request for a part of the medical record

I would like to request a part of my medical record

What documents would you like exactly? (please list)

Site

Ste-Elisabeth

St-Michel

If other examination, please specify:

Request for a copy of a medical file

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