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 Fontaine Alice

For the attention of Parent de Alice

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

Total fees (4 sessions)	153,48 €
Amount to be paid by the patient	153,48 €

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: