Application Form

BARIATRIC APPLICATION FORM

The risk of intervention is associated with the patient body constitution and negative factors he/she has been exposed to in the past. In order to determine those risk factors on time, please answer the following questions

GENERAL INFORMATION

MEASURES

DIET HISTORY

PERSONAL HEALTH

PREVIOUS SURGERIES

FAMILY HEALTH

CURRENT MEDICATIONS

PREVIOUS MEDICATIONS

MAJOR ILLNESSES YOU HAND

ADDITIONAL INFORMATION

PREFERED TYPE OF SURGERY

PREFERED DATE

First Name

Last Name

E-mail

Date of brith

Age

Phone No.

Occupation

Height, cm

Weight, kg

BMI

Highest weight in life, kg

How long have you been overweight

What have you done to try to lose weight?

Are you a snacker?

Are you a volume eater?

Do you eat a lot of food containing sugar?

Do you frequently eat fast food and/or drink carbonated beverages?

What foods or drinks cause you digestive problems?

Do you drink alcohol? If yes, please tell us how often and how much:

Do you smoke? If yes, please tell us how often and how much:

Do you have any other addictions?

Diabetes ( type/medications )

Cancer ( type )

Overweight

Obesity

Heart disease ( type )

High bood pressure

Gastric symptoms ( type )

Do you experience shortness of breath with physical activity?

Do you exercise regularly?

Do you have or had asthma?

Do you have thyroid problems?

Do you have any allergies?

Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?

Do you have indigestion or heart burn?

Have you been diagnosed for lupus?

Have you been diagnosed HIV positive?

Diabetes (Family member/type)

Cancer (Family member type)

Overweight (Family member)

Obesity (Family member/type)

Heart disease (Family member)

High blood pressure (Family member/type)

Other (Family member)

Surgery

Reason

Date

Medication / How often taken

Reason

Date started

Medication / How often taken

Reason

Date started

Illness / Date

Treatment / Outcome

Please list any additional information you believe would help us to form a better view of your current health condition

Gastric Bypass. Gastric Sleeve. Gastric Plication. Gastric Ballon. Revision Surgery

Surgery date

I confirm that I fully understand what personal data is being collected from me and for what reasons through this online form. I also confirm that I fully understand the confidentiality agreement between BALTICLINIC and myself.

Yes

Date of filling out the form

We respect our patients’ privacy and guarantee that your personal information will not be misused. Read our

Fleur de lis

tummy tuck

From €3400

Fleur de lis

tummy tuck

From €3400

Contact Us Now via WhatsApp +370 632 60600

STEPS FOR MEDICAL TRAVEL

Write us a message and we will gladly answer to all of your questions about the procedure.️

We will arrange a free online consultation.

We will book your appointment date.

️Flight tickets, hotel reservation. You can do it on your own or we can help you with all recommendations.

Then in Lithuania, we will greet you at the airport and your private driver will take you to the clinic for a personal consultation with a doctor.

Night at the hotel before your procedure.

️In the morning of your surgery, your private driver will pick you up from the hotel and take you to the clinic.

Your assistant will be with you all the time so you can feel as comfortable as possible.

After the surgery, you will stay at our clinic for 1-2 nights depending on your procedure in a luxury room with all amenities. Our professionals will take exceptional and individual care of you 24 hours a day.

Before discharge, you will meet your surgeon, he will also explain to you all postoperative care details. You will get your medication set.

Your assistant will be in contact with you all the time during your stay and after flying back home. There is no need to worry about travelling alone as every minute of your stay you will feel cared and supported.

Your personal coordinator will be the person who you will speak to or receive the first email from. Your coordinator will happily answer any questions you might have and guide you through all information you may need by providing you with the support in your plastic surgery journey.

Your personal driver will greet you at the airport for your private airport transfer. During your stay in Lithuania, we provide all your transportation between the airport, hotel and clinic.

FREE SURGEON CONSULTATION

Send us your enquiry

E-mail is used as a means of contacting the customer and giving advice on the request.

Phone number is used as a means of contacting a customer and giving advice on the request

We respect our patients’ privacy and guarantee that your personal information will not be misused. Read our Privacy policy.

MOST POPULAR

Weight Loss Surgery
Tummy Tuck
360 Body Lift
Mommy Makeover
Breast Reduction & Lift

ABOUT US

Why BaltiClinic?
Doctors
Privacy Policy

CONTACTS: Savanorių 284, Kaunas, Lithuania

BOOK OUR CLINIC APARTMENTS IN KAUNAS NEAR CLINIC

Fleur de lis

tummy tuck

From €3400

Fleur de lis

tummy tuck

From €3400

STEPS FOR MEDICAL TRAVEL

Write us a message and we will gladly answer to all of your questions about the procedure.️

We will arrange a free online consultation.

We will book your appointment date.

️Flight tickets, hotel reservation. You can do it on your own or we can help you with all recommendations.

Then in Lithuania, we will greet you at the airport and your private driver will take you to the clinic for a personal consultation with a doctor.

Night at the hotel before your procedure.

️In the morning of your surgery, your private driver will pick you up from the hotel and take you to the clinic.

Your assistant will be with you all the time so you can feel as comfortable as possible.

After the surgery, you will stay at our clinic for 1-2 nights depending on your procedure in a luxury room with all amenities. Our professionals will take exceptional and individual care of you 24 hours a day.

Before discharge, you will meet your surgeon, he will also explain to you all postoperative care details. You will get your medication set.

Your assistant will be in contact with you all the time during your stay and after flying back home. There is no need to worry about travelling alone as every minute of your stay you will feel cared and supported.

​

Your personal coordinator will be the person who you will speak to or receive the first email from. Your coordinator will happily answer any questions you might have and guide you through all information you may need by providing you with the support in your plastic surgery journey.

​

Your personal driver will greet you at the airport for your private airport transfer. During your stay in Lithuania, we provide all your transportation between the airport, hotel and clinic.

FREE SURGEON CONSULTATION

Send us your enquiry

E-mail is used as a means of contacting the customer and giving advice on the request.

Phone number is used as a means of contacting a customer and giving advice on the request

We respect our patients’ privacy and guarantee that your personal information will not be misused. Read our Privacy policy.

MOST POPULAR

Weight Loss Surgery Tummy Tuck 360 Body Lift Mommy Makeover Breast Reduction & Lift

ABOUT US

Why BaltiClinic? Doctors Privacy Policy

CONTACTS: Savanorių 284, Kaunas, Lithuania

BOOK OUR CLINIC APARTMENTS IN KAUNAS NEAR CLINIC

Weight Loss Surgery
Tummy Tuck
360 Body Lift
Mommy Makeover
Breast Reduction & Lift

Why BaltiClinic?
Doctors
Privacy Policy