Belgium

These are the areas in which we currently have a
Liaison in this Country

92 Rue Verboeckhaven, Belgium

Vooruitgangstraat 15, Belgium

Please fill out this form and we will supply you with the contact
information of the Liaison in your area.
Please allow 2-3 days for processing.
Title: 
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First Name: 
   * 
Last Name: 
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Street  Address: 
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   (Apt, Unit, etc.)
City: 
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State or  Province: 
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If not listed above, please enter below:  
 
Country: 
 
If not listed above, please enter below:  
 
Zip or Postal Code: 
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If this does not apply to you please type in N/A
Phone Numbers: 
Country Code ("1" for US and Canada)
Area Code or Intl City Code (if reqd.)
Your Local Number
Phone: 
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E-mail: 
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Area of Liaison:
(Please choose from
list above)
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Person requesting liaisons contact is:
(Check all that apply)
Patient GBS
Caregiver CIDP
Child (Birth - 18 yrs.) Miller Fisher
Other - (note in comments)
Reason for requesting
Liaison contact: