Requesting a one-off medical check

Even if you’re not yet a Certimed client, you can request medical checks on a one-off basis. This allows a check-up to be scheduled immediately, and you also become a client at the same time. Convenient, isn’t it? To arrange this, we need the information below from you.

A consultation at a doctor’s office costs €90.52. A check at the employee’s home costs €132.10. These amounts are exclusive of a one-off affiliation charge of €52.57.

You will receive confirmation of the check-up appointment as soon as possible.

All prices listed are exclusive of VAT.

Your company details

Company name *
Location or department
Street *
House number *
Box number
Postcode *
Town/city *
Country *
Enterprise number *

Your enterprise number is the same as your VAT number, but without ‘VAT BE’ in front.


The requesting party: personal details

Note: The results of the medical check will be automatically sent to the designated contact person listed below. If you would like to change these details, send us an email at info@certimed.be and we’ll be happy to help.

First name *
Surname *
Language *
 
Email address *
Phone number *
Position *
 


Employee to be checked: personal details

First name *
Surname *
Date of birth (DD/MM/YYYY) *
Identification (personnel number or national register number)
Language *
 
Email address (we will only use this for a consultation)
Phone number (we will only use this for a consultation)
Street *
House number *
Box number
Postcode *
Town/city *
Country *
Type of check *
 


Information about the employee’s absence

If you have opted for a home visit and the check cannot take place at the home address of the employee concerned, give the address where the check should take place:
Person has been unfit for work since (dd/mm/yyyy) *
Person will be unfit for work until (dd/mm/yyyy) *
Type of absence certificate *
 
Employee is allowed to leave home *
 
Check within the certificate period at a convenient time *
 
Date (dd/mm/yyyy)
Additional information for the checking physician
Requesting a one-off medical check - Mensura