medical certificate (Annex)

(Application of the law of the 15/12/1980 on the access to the territory, the stay, the establishment and the alienation of the foreigners)

(Other than art 10 – 10bis)

The undersigned Doctor in medicine (full name) ……………………………….……………………………………..

Certifies that he/she has examined this day Mr./Mrs./Miss (full name) ……………………………………………………………………………………………………………………………………………………………………………….………..

Nationality ………………………………………………………………………………………………………………………….………..

Date and place of birth ……………………………………………………………………………………………………….……...

Residing at …………………………………………………………………………………………………………………………….….…

And has found him/her free of:

  1. Diseases being able to endanger the public health:
  1. Illnesses requiring quarantine aiming in the international regulation n°2 of May 25, 1951, of the World Health Organization;
  1. Pulmonary tuberculoses, active or progressive
  1. Syphilis
  1. Other infectious diseases or contagious parasitoses in so far as they make, in the host country, the object of provisions of protection with regard to the nationals
  1. Diseases and infirmities being able to endanger the law and order or public safety:
  1. Toxicomania
  1. Blatant psychological aberrations; manifest states of psychotic behavior; delirious or hallucinatory psychosis

Issued at…………………………………………………………….at ……..……….…………………………………………………

Signature of doctor ……………………………………………………………….………….…………………………………………

Stamp of doctor’s office …………………………………………………………….……………………………………………….

Le cas échéant / In voorkomend geval,

Visa de l’Ambassade ou du Consulat Général

Visum van de Ambassade of het Consulaat-Generaal (Sceau/stempel)

À/te ………………………………………………………….le/op ……………………………………………………………………

Annex:

  1. Diseases being able to endanger the public health:
  1. Illnesses requiring quarantine aiming in the international regulation n°2 of May 25, 1951, of the World Health Organization;

cholera; bubonic plague, smallpox, yellow fever

  1. Pulmonary tuberculoses, active or progressive
  2. Syphilis
  3. Other infectious diseases or contagious parasitoses in so far as they make, in the host country, the object of provisions of protection with regard to the nationals

typhus exanthema; febris recurrens; polio; epidemic influenza; typhoid and paratyphoid fever; salmonelloses; sighelloses; diphtheria ;scarlet fever; contagious forms of leprosy; epidemic cerebro-spinal meningitis; febris ondulans; puerperal streptococcus; pemphigus neonatorum; epidemic diarrhoea neonatorum; Erysipelas neonatorum; viral encephalitis; infectious hepatitis; rabies; haemorrhagic or non-hemorraghic pyrecia caused by: arbo virus or toga virus, arena virus, rhabdo virus, ricketsioses, ornithosis, psittacosis, amoebic and other forms of dysentery, gonorrhoea, the illness of Nicolas & Favre - ulcus molle - infectious dermatitis, whooping cough, mumps, measles, rubella, chicken pox

  1. Diseases and infirmities being able to endanger the law and order or public safety:
  1. Toxicomania
  2. Blatant psychological aberrations; manifest states of psychotic behavior; delirious or hallucinatory psychosis

Please note that only the form in French or in Dutch can be completed.

This translation is provided only to help you!