Online appointment form - Radiology

Name of requesting doctor

Speciality

Site

Erasme Hospital

Lothier Polyclinic

Examination request

One file only.
64 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, odt, odp, ods, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Type of examination

MRI

CT - Scanner (Erasme Hospital only)

Ecography

Digestive X-Ray

Conventional X-ray

I don't know

Gender

Male

Female

Your details

Nom

Prénom

National register identification number (NISS)

Mobile phone number

Email address

Date of birth

New patient? Give us your address:

Street, number, box

Postcode

Locality

Country

Comments

I agree to take my exam at HUDERF if the deadlines are shorter.

Yes

HUDERF is located avenue Jean Joseph Crocq 15 in 1020 Brussels (Laeken)

I agree to take my exam at Bordet if the deadlines are shorter.

Yes

The Jules Bordet Institute is on the same site as the Erasmus Hospital in Anderlecht.