Partners

Gebruikersaccount

Thank you for setting up a profile. Your application will be reviewed shortly after you submit the form. Your membership will be activated after your membership fee is received.

You will be notified by email once the webmaster has approved your application.

Account-informatie

Gebruikersnaam: *

Spaties zijn toegestaan; interpunctie is niet toegestaan behalve punten, koppeltekens en onderstrepingstekens.

E-mailadres: *

Geef een geldig e-mailadres op. Alle e-mails van dit systeem zullen naar dit adres verstuurd worden. Het e-mailadres zal niet openbaar gemaakt worden en zal alleen gebruikt worden wanneer u om een nieuw wachtwoord vraagt of wanneer u over bepaald nieuws per e-mail geïnformeerd wil worden.

General profile

First Name *

Last Name *

Gender *

Female Male Transgender (wissen)

Birth Date *

(wissen)

Professional profile

Your professionnal profile will be available to the public

Professional status *

Hospital/Institution/Company/Practice Name

Professional Address *

Professional Zip Code *

Professional Location *

Professional Country

Professional Telephone *

Please use international format: +32 2 2221100

Professional Fax

Please use international format: +32 2 2221100

Professional E-mail Address *

Hospital/Institution/Company/Practice Name

Your secondary office

Professional Address

Secondary professional Zip Code

Professional Location

Professional Country

Professional Telephone

Please use international format: +32 2 2221100

Professional Fax

Professional E-mail Address

RIZIV/INAMI number

Home profile

Your home profile is optional and will only be available to registered reumatologists and professionals.

Home Address

Home Zip Code

Home Location

Home Country

Home Telephone

Please use international format: +32 2 2221100

Home Fax

Please use international format: +32 2 2221100

Home Cellphone

Please use international format: +32 2 2221100

Home E-mail Address

Communication profile

Mail Address *

E-mail Address *

Motivation and comments

Motivation *

Please fill out a short motivation for your account request.

Questions or comments

Contact

SRBR-KBVR

Winston Churchilllaan 11 b30, 1180 BRUSSEL

Tel : 00 32 2 372 36 43

Fax : 00 32 2 375 48 13

Op ma & di van 9u tot 17u, do van 9u tot 16u

Rekening nummer : 360-0105641-14

Info : srbrkbvr [at] skynet [dot] be

Fietsen tegen Reuma

Fietsen samen met patiënten en hulpverleners, oa. verpleegkundigen, kinesisten, reumatologen en vele sympathisanten tegen reuma ! www.fietsentegenreuma.be