Contact details
First name *
Last name *
Personal identification number *
City/town *
Street, building No., Apartment No. *
City district *
Date of birth *
Email *
Phone number *
Occupation (important for identification of any potential medical conditions) *
I have discovered Kaunas Denticija thanks to:
Recommendation by a friendI have noticed it while walking byInformation onlineInfo servicesInformation in leaflets/pressOther...
Please, tick the option which applies to You (in case of an existing or pre-existing medical condition)
Hepatitis A/B/C: YES / NO
Diabetes: YES / NO
Heart diseases: YES / NO
Blood coagulation issues: YES / NO
Fainting: YES / NO
High blood pressure: YES / NO
I take drugs at present: YES / NO
Epilepsy: YES / NO
Low blood pressure: YES / NO
Cardiac pacemaker: YES / NO
I am an HIV carrier: YES / NO
for women! Pregnancy from*
for women! Pregnancy to
Are you allergic to medicine? *
I had chemotherapy (date) *
Are you allergic to anything else? *
I had radiation therapy (date) *
Other illnesses *
I would like to receive SMS reminders about my visits, congratulations and notifications by SMS and/or email. Agree
I would like to receive invitations for regular preventive oral and dental checkups. In case any changes occur in my medical conditions in the course of treatment, I undertake to notify the Clinic on any such changes. Agree
I acknowledge that the data provided by me are correct and I give my consent to their use as may be needed by this entity.