Part of the NEWMAN Clinic

Other services

Let us guide you

Receive individual consultation from our dedicated team member

Consult us

Application form for plastic surgery - EN

"*" indicates required fields

General information

Hidden
Hidden
MM slash DD slash YYYY
Hidden
Hidden
Hidden

Past and present medical conditions

Heart and vascular system (Blood pressure / myocardial infarction / heart failure / angina pectioris, etc.)*
Respiratory system (pneumonia / Chronic bronchitis / pulmonary tuberculosis, etc.)*
Do you have varicose veins?*
Have you ever had thrombosis or thromboembolism?*
Liver, biliary system (liver infammation / liver cirrhosis / tumors / bile duct stones / gall bladder inflammation, etc.)*
Digestive system (stomach ulcer / inflammation / gastroesphageal reflux disease and others)*
The urinary system (kidney inflammation / swelling / inflammation of the bladder, etc.)*
Internal secretion system (thyroid, adrenal disease, tumours, diabetes / spleen, etc.)*
Nervous system (epilepsy / stroke / paralysis, etc.)*
Mental system (depression / eating disorder / panic attacks, etc.)*

Blood clotting system:

Does bruises occur spontaneously, as if without a cause?*
Do you bleed long after injury?*
Wound healing disorders (your wounds was ever formed abscesses, fistulas, etc.) ?*
Do you have acute or chronic infectious diseases (ex: Hepatitis, HIV, etc.)?*
Do you have autoimmune disease?*

Surgeries and anaesthesia

Have you had any previous surgeries?*
Where threre any complications during or after the surgery?*
Have you ever had anaesthesia?*
If yes, what kind of anaesthesia did you have?
Have you had any problems with anaesthesia?
Are you taking any medications?*
Are you allergic?*

If you answered yes, please write allergens:

Smoking / alcohol / drugs

Do you smoke?*

If you answered yes, please describe in more detail:

Do you drink alcohol?*
If answered yes, how often do you use alcohol? Once a:
Do you use drugs?*
Do you have any loose teeth?*

Women only

Will the surgery coincide with your menstrual period?
Is there a possibility, that you are pregnant at the moment?
Are you taking birth control pills?

Major illnesses you had

List*
Illness / Date
Treatment / Outcome
 

Previous surgeries

List*
Surgery
Reason
Date
 

Current medications

List*
Medication / How often taken
Reason
Date started
 

Your special needs during Your stay in Lithuania

Prefered type of surgery

Preffered surgery date

MM slash DD slash YYYY
Hidden
Hidden
Drop files here or
Max. file size: 64 MB.
    Consent*
    This field is for validation purposes and should be left unchanged.