Jules Bordet Institute | Making appointment

This appointment request is

for you

not for you

Patient's name

First name's patient

Birth day of the patient

Has the patient ever been treated at the Institut Bordet?

yes

National Register Number

If YES, your file number (if known)

In which department or doctor / provider do you want a consultation or examination

Desired clinic

Possible remarks

Name of the contact person

Telephone, GSM ... of the contact person

Contact email

When do you want to be contacted?

Name of attending physician

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