Laboratory - Results server access request

Dear Doctor,

If you would like to have access to the CGM CHANNEL results server, please complete the form below.

Please note that access to this server is protected by an individual, personalized password. This password must be kept confidential by the user to allow control of each user's activity on the server.

This password may not be passed on or entrusted to a third party, or made accessible to a third party.

SURNAME*

First name*

INAMI/RIZIV Nr*

Telephone number*

E-mail address*

Home address*

Address(es) of your private practice(s)*