New File

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Contact person

Please tick this box if you are the patient

Relation to the patient *

Family name *

First name *

Sex *

Language *

Patient's personal details

Retrieve patient data by means of their national register number

Family name *

First name *

Date of birth *

Sex *

Nationality *

Language *

Address *

Postal code *

City *

Country *

PATIENT'S HEALTH INSURANCE DETAILS

Name of the mutuality *

National register number *

- OR -

Policy number *

Name private insurance

Insurance is contacted. If so please note down the reference number.

Insurance is not (yet) contacted. If so please note down the policy number.

TRAVEL INFORMATION

Travel purpose *

From *

Number of fellow travellers *

Means of transport

Flight information

Flight number to

Flight number back

Airline company

Tour operator

Information of the travel companion / travel contact

Please tick this box if you are the travel companion

Family name

First name

Relation to the patient

accomodation

Type of accommodation + name *

Address

Postal code

City *

Country *

MEDICAL INFORMATION

Admission

Outpatient treatment

Declaration of costs

Admission form

General practitioner in Belgium

Name general practitioner *

Postal code of the general practitioner

City of the general practitioner *

Specialist in Belgium

Name specialist in Belgium

Treating doctor abroad

Name treating doctor abroad

Treatment details abroad

Hospital

City

Country Hospital *

Ward/floor

Room number

Start treatment *

End treatment

Diagnosis *

Outpatient treatment form

General practitioner in Belgium

Name general practitioner *

Postal code of the general practitioner

City of the general practitioner *

Specialist in Belgium

Name specialist in Belgium

Treating doctor abroad

Name treating doctor abroad

Treatment details abroad

Hospital

City

Country Hospital *

Start treatment *

End treatment

Number of treatments

Diagnosis *

Declaration of costs form

Date of treatments *

Diagnosis *

City

Please tick this box if you require further assistance

ADD DOCUMENTS

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ASSISTANCE REQUEST/REMARKS

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