My Appointment - Nuclear medicine

Appointment request - Nuclear medicine

Request for examination

Name of requesting doctor

Speciality of the requesting doctor

Request for examination

One file only.
64 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Type of examination

Pet scan

Scintigraphy

Osteodensitometry

Please note: depending on the specific nature of the examination requested, you may be contacted by the Hôpital Erasme or the Institut Jules Bordet (located on the Anderlecht campus).

Your data

Name

First name

Gender

Female

Male

I prefer not to say

Date of birth

National register identification number

Mobile phone number

Email address

Are you a new patient? Send us your details:

Street, number, box

Postcode

City

Country

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