Name : ....................................

Hospital : .................................

Address : ................................... ................................................

City : ........................................

Phone : ....................................

E-mail : ...................................

SEND BACK BEFORE November 11th by mail:

Mrs M. Milecan, Dept Radiology

Av. Hippocrate 10/2942,

B - 1200 Brussels

by fax : + 32 2770 5574

by e-mail : Martine.Vanwambeke@uclouvain.be