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22/09/2011
MEDICAL CERTIFICATE
(Application of the law of 15/12/1980 on the access to the territory, stay, establishment and alienation of
the foreigners)
I, undersigned Doctor in medicine (full name)…………… ……………………………………………………...…
Certifies
that I have examined Mr./Mrs./Miss
(full name)…………….…………………………………………...
…………………………………………………………………………………………………………………………...
Nationality.………………………………………………………………………………………………………………
Date and place of birth….…………………………………………………………………………………………..…
Residing at. ……………………………………………………………………………………..……………………...
And has found him/her free of the following illnesses which can endanger the public health:
1. Illnesses requiring quarantine as stated by the International Sanitary Regulation of the World
Health Organization, signed in Geneva on 23 May 2005;
2. Pulmonary tuberculosis active or progressive;
3. Other contagious or transmittable diseases by infection or parasites if they are subject in
Belgium to provisions of protection of the nationals.
Issued at ……………………………….... on……………………… ………………………………………….……..
Signature of doctor…………………………………………………………………………………………………..…
Stamp of doctor’s office………………………………………………………………………………………………..
If applicable,
Visa of the Embassy, Consulate general or Consulate (Seal)
At………………………………, on ………….…………..
