Registration and onboarding

Will you soon be starting work at Maria Middelares General Hospital as a physician-specialist in training? Please complete this questionnaire as completely and accurately as possible, at least four weeks before the start of your internship.

Many thanks for providing your information, and please feel very welcome in our hospital!

Ga verder met itsme

Assistantship

Type of assistantship

Free assistants contact Saïs Walenta via sais.walenta@azmmsj.be. Interns (sixth-year master's degree in medicine) register via the student section (Go to Professionals > Interns and students).

Start date assistantship

End date assistantship

Discipline at the start

How many years of specialization?

University

General information

Last name

First name

Gender

Nationality

Date of birth

Birthplace

Country of birth

ID card number

National Register Number

RIZIV number

Address details (domicile)

Address

Postal code

City

Country

Contact details

Cellphone number

For example: +32 XXX XX XX XX

E-mail address

Bank account number

IBAN

Example: BEXX XXXX XXXX XXXX

Marital status

Marital status

You are obliged to state your partner below. Even if you are unmarried, but have a partner, please complete the fields below. If you do not have a partner, fill in the fields below with 'NA' (Not Applicable).

Last name partner

First name partner

Date of birth partner

Birthplace partner

Nationality partner

Profession partner

Number of dependent (foster) children?

Other dependents?

Practical

Do you have to wear a dosimeter during your internship?

Are you coming by car?

Number plate car 1

Number plate car 2

Doctor's coat size

Passport photograph

Upload a passport photo below (jpg). We expect a professional photo, in accordance with the standards as on your identity card. This means in civilian clothes with a neutral, white background. The photo is necessary to create your badge.

I agree to the terms of use, privacy policy and cancellation terms.

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