IBIS profile - Mandate request

Please complete the following form to obtain access to a profile for which you are the representative

Data of the applicant (representative)

Name

First name

Date of birth

Address

Postal code

City

Email address

Phone number Belgian or international format accepted (e.g., 0495 12 34 56, +32 495 123 456, +33 6 12 34 56 78)

Subject data (minor patient or legal guardianship)

The relationship between representative and subject

Name

First name

Patient id number

National register number

Files to download (pdf, jpeg, png)

Preuve de validité de la demande

Representative ID card (front)

Representative ID card (back)

Subject ID card (front)

Subject ID card (back)

By submitting the form, you consent to the processing of your data following the Privacy policy of Europe Hospitals.

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