Application form for bariatric surgery

Bariatric surgeon Antanas Mickevicius MD, PhD;
  • Please give us your general information

  • Please fill in your measures

  • Please tell us about your diet history

  • Please tell us about your personal health history

  • Please tell us about your family health history

  • Please list any previous surgeries you have had

  • SurgeryReason / date 
  • Please list any current medications you are taking

  • Name of medication / How often takenWhen use started / Reason 
  • Please list any major illnesses you have had

  • Illness / DateTreatment / Outcome