Fill out our application survey

If you are unsure about any of the questions and the answer is “I don’t know”, we will assess it during the consultation.

Gastric (hiatal) hernia? *
Abnormality of the oesophagus? *
Acute gastritis (individual assessment in cases of chronic gastritis) *
Ulcers ((oesophageal ulcer; gastric ulcer; duodenal ulcer) no contraindications in case of previously healed ulcers))? *
Any gastric or oesophageal surgery (anti-reflux surgery; bariatric surgery for gastric reduction; laparoscopic band ligation) *
Existing gastric balloon currently in the stomach? *
Severe gastroparesis? *
Chronic constipation (drug managed? *
Diverticulosis? *
Appendicectomy with incision (laparoscopic surgery is not a contraindication? *
Perforated appendix and surgery? *
Crohn's disease? *
Adhesions after bowel surgery? *
Inability to discontinue regular use of non-steroidal anti-inflammatory drugs (ibuprofen, diflocan, paracetamol) or other drugs irritating the stomach? *
Use of anticoagulants, inability, or unwillingness to take (PPI drugs)? *
Heart failure? *
Liver failure, cirrhosis? *
Blood clotting disorders? *
Serious or uncontrolled mental illness? *
Eating disorders (bulimia, compulsive eating)? *
Alcoholism, drug addiction? *
Pancreatitis? *
Severe respiratory disease (COPD, sleep apnea)? *
Cancer? *
Known allergy to polyurethane? *
Pregnant and breastfeeding women? *
Name *
Surname *
Email *
Phone number *
Preferred method of communication *