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IBIS profile - Deletion of mandate

Please complete the following form to request deletion.

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Patient data (subject)

Name

First name

Date of birth

National number

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)

Patient number

Representative data (parent or legal guardian)

Name

First name

Date of birth

National number

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)

Patient number

Reason for cancellation

Reason

Minor becoming an adult

End of the legal incapacity regime

Other

Specify the reason

Files to download (pdf, jpeg, png)

Proof of the validity of the request

As a patient, I wish to revoke the mandate associated with my medical file made available on the Europe Hospitals patient platform.

I request and accept that the representative no longer has access to my patient file on the patient platform.

. .