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Camille Renard
Speech therapist, INAMI no. 6-00000-05-111
Rue de la Démonstration 1, 1000 Bruxelles
Tel. 0400 00 00 00 · demonstration@exemple.be
Enterprise no. 0123.456.749
To the parents of Leroy Zoé
For the attention of Parent de Zoé
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice

Issued on 25/10/2026

Sessions of September 2026 · DRAFT, do not send

Patient and prescription

Patient
Leroy Zoé
Date of birth
28/06/2021
National register no.
21.06.28-141.16
Health insurance fund
Mutualité de démonstration Nord
INAMI code
713311
Prescribed by
Dr Martin, pédiatre
Prescription of
26/08/2025
Doctor's INAMI no.
10000007000
Medical advisor's approval
25/09/2025
Approval period
10/09/2025 to 09/09/2027

Breakdown of services

Session date INAMI code Fee
08/09/2026 713311 38,37 €
15/09/2026 713311 38,37 €
22/09/2026 713311 38,37 €
29/09/2026 713311 38,37 €
Total fees (4 sessions)153,48 €
Amount to be paid by the patient153,48 €

BIM patient: no. Enterprise no. 0123.456.749.

Healthcare services exempt from VAT (article 44, § 1, paragraph 1, 1°, of the VAT Code).

Camille Renard, speech therapist, INAMI no. 6-00000-05-111, certifies having provided the services listed above.

Date:
Signature of the provider: