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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
Dupont Léa
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice

Issued on 27/10/2026

Sessions of September 2026 · DRAFT, do not send

Patient and prescription

Patient
Dupont Léa
Date of birth
12/07/1968
National register no.
68.07.12-131.16
Health insurance fund
Mutualité de démonstration Sud
INAMI code
718314
Prescribed by
Dr Lambert, ORL
Prescription of
10/12/2025
Doctor's INAMI no.
10000007000
Medical advisor's approval
09/01/2026
Approval period
25/12/2025 to 24/12/2027

Breakdown of services

Session date INAMI code Fee
11/09/2026 718314 38,37 €
18/09/2026 718314 38,37 €
25/09/2026 718314 38,37 €
Total fees (3 sessions)115,11 €
Amount to be paid by the patient115,11 €

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: