Weight loss revision surgery can be an emotional decision. If a person had knee surgery that was initally effective, but after a few years some pain returned and the surgeon had to make an additional repair, a person wouldn't feel like they were a failure. Weight loss surgery should be no different. If you're interested in helping remove the stigma, shame and guilt from weight loss revision surgery, we'd like to invite you to help us reach others with the message.    Now's your chance to share some personal advice that may make an important difference in someone else's life. Please answer each question and include both before and after photos. You may mail or email your photos.   Email pictures to:  dhart@chathamcommunications.com Mail pictures to:  Barix Clinics Marketing Department 135 S. Prospect Ypsilanti, MI  48198 Attention:  Share Your Story

Check those that apply: I am emailing before & after pictures I am mailing before & after pictures CONTACT INFO FIRST NAME  * required LAST NAME  * required MAILING ADDRESS  * required CITY  * required STATE  * required ZIP CODE  * required DAYTIME PHONE (XXX-XXX-XXXX)  * required EMAIL ADDRESS  * required     TELL US ABOUT YOUR INITIAL SURGERY REASON FOR HAVING SURGERY --Select One-- Improve Health/Medical Conditions Improve Overall Quality of Life Increase Life Expectancy Improve Confidence/Self-Esteem Improve Ability to Participate in Family Activities Other IF OTHER: TYPE OF SURGERY --Select One-- Roux-en-Y Gastric Bypass LapBand Gastric Sleeve SURGERY DATE (MM/DD/YYYY) DID YOU HAVE YOUR SURGERY AT BARIX CLINICS? Yes No    WEIGHT LOSS EXPERIENCE Did your weight come off quickly? Did you reach your personal goal weight? Did you experience long plateaus?  WHAT CONTRIBUTED TO WEIGHT GAIN? (Stress, injury, medications, illness, food choices, surgery failure, etc) WEIGHT HISTORY HIGHEST WEIGHT (lbs) SURGERY WEIGHT (lbs) Initial bariatric surgery  LOWEST WEIGHT (lbs) SURGERY WEIGHT (lbs) Bariatric revision surgery  CURRENT WEIGHT (lbs) MEDICAL CONDITIONS BEFORE Initial Surgery NOW Sleep Apnea Sleep Apnea Diabetes Diabetes High Blood Pressure High Blood Pressure Joint Pain Joint Pain Gout Gout High Cholesterol High Cholesterol

TELL US ABOUT YOUR REVISION SURGERY WAS IT DIFFICULT TO ASK FOR HELP? HOW DID YOUR SURGEON RESPOND? TYPE OF REVISION SURGERY --Select One-- LapBand Removed - Bypass Surgery LapBand Removed - Sleeve Surgery LapBand over Bypass Gastric Bypass Stoma Reduction Sleeve to Bypass Other SURGERY DATE (MM/DD/YYYY) WHAT IS DIFFERENT THIS TIME? WHAT WOULD YOU LIKE TO TELL OTHERS CONSIDERING REVISION SURGERY? HAVE YOU IMPLEMENTED ANY NEW STRATEGIES TO HELP YOU REACH AND MAINTAIN A HEALTHY WEIGHT? Terms & Conditions: I have been informed that Forest Health Services, LLC (Forest Health) wishes to arrange to take or use still photographs, motion pictures and/or videotapes (Photographs) and/or to publish or broadcast an article, testimonial, endorsement, advertisement or story (Stories) of or about me and my medical condition as a patient at a Barix Clinics facility (if applicable). I understand that if I sign this consent form, I will authorize Forest Health to take or use Photographs of me and/or to publish or broadcast the Photographs and/or Stories. I also understand that I do not have to sign this consent form in order to receive continued medical treatment. I further understand that Forest Health and its affiliated entities are involved in the preparation of a portion or all of the Stories. I further understand that I will not endorse, sponsor or appear in any other Photographs or Stories promoting a bariatric treatment program relating to bariatric treatment other than for those affiliated with Barix Clinics for a period of three (3) years after the date of this authorization. I understand this restriction does not prohibit me from writing about or making personal appearances to talk about my personal experience with weight loss, provided that in so doing I do not endorse or sponsor a bariatric treatment program other than Barix Clinics. I hereby consent to allow Forest Health to take or use Photographs of me and to publish and/or broadcast the photographs and/or Stories in a manner than may identify me by name or likeness. I release Forest Health and its affiliated entities, staff, agents, and employees from any and all liability as a result of the Photographs, or Stories done about me and my medical condition. I hereby certify that I have had an opportunity to ask any questions that I may have and that any such questions have been answered to my satisfaction. I have read and agree to the terms above I do not agree to the terms above