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REQUEST FORM

Contact person:

Relation between the contact person and the person being cared for:
Who will be the client in the contract?

Information about the patient

Person 1

Smoking

Person 2

Smoking
Diseases

Is there additional medical or social assistance?

Communication disorders:
Speech:
Hearing:
Vision:

Orientation:

Movement:
Climbing stairs:
Are there additional technical support means?:
Hygiene:
Toilet :
Rengimasis:
Eating/drinking :
Sleeping
Additional treatments

Requirements for personnel

Gender:
Age:
Driving licence:
Smoking:
Living conditions :

Daily routine oft he patient:

Morning

Before noon

Noon

Afternoon

Evening


We really do - we care!

PRIVACY POLICY


Baltijos optimalūs sprendimai, VšĮ
Company code: 304286000
VAT code: LT100010287410

Phone +370 607 21893
E-mail info@baltic-care.lt


Baltija LT, VšĮ
Company code: 304896651
VAT code: LT100011917812

Phone +370 614 57526
E-mail info@baltic-care.lt

You can find us at:
Mainų str. 31, 94101 Klaipėda

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