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Tom Exemple
Speech therapist, INAMI no. 6-00022-20-222
Rue de la Démonstration 1, 1000 Bruxelles
Tel. 0400 00 00 00 · demonstration@exemple.be
Enterprise no. 0234.567.873
Collin Antoine
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice

No. TE-2026-001 · Issued on 25/10/2026

Sessions of September 2026 · CANCELLED

Patient and prescription

Patient
Collin Antoine
Date of birth
14/07/1959
National register no.
59.07.14-139.50
Health insurance fund
Mutualité de démonstration Sud
INAMI code
712611
Prescribed by
Dr Simon, neurologue
Prescription of
23/01/2026
Doctor's INAMI no.
10000007000
Medical advisor's approval
22/02/2026
Approval period
07/02/2026 to 06/02/2028

Breakdown of services

Session date INAMI code Fee
07/09/2026 712611 77,05 €
14/09/2026 712611 77,05 €
21/09/2026 712611 77,05 €
Total fees (3 sessions)231,15 €
Amount to be paid by the patient231,15 €

BIM patient: no. Enterprise no. 0234.567.873.

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

Tom Exemple, speech therapist, INAMI no. 6-00022-20-222, certifies having provided the services listed above.

Date:
Signature of the provider: