Your success story is a powerful source of hope and encouragement for those considering bariatric surgery.    Congratulations on your success!  We sincerely believe that no one can tell the story like someone who has been there.  You know what it is like to be severly overweight and you've also experienced the dramatic weight-loss associated with bariatric surgery.  So, if you're interested in helping people find out about the Barix Clinics program, then we'd like to invite you to help us reach them.  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:  marketing@barixclinics.com Mail pictures to:  Barix Clinics Marketing Department 135 S. Prospect Ypsilanti, MI  48198 Attention:  Share Your Story Our privacy pledge:  We respect your privacy.  We only ask for this information to help Barix Clinics communicate the message about our program to others.  Rest assured that your personal information will be kept in the strictest confidence and we will not share this information with any non-affiliated third parties-that means it will only be used for Barix advertising.  Questions:  Contact Marketing at 800-282-0066

Contact Info First Name  * required Last Name  * required Mailing Address  * required City  * required State  * required Zip Code  * required Home Phone (XXX-XXX-XXXX)  * required Email Address  * required General Info 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: Surgery Type --Select One-- Roux-en-Y Gastric Bypass LapBand Gastric Sleeve Surgery Date (MM/DD/YYYY) Check those that apply: I am emailing before & after pictures I am mailing before & after pictures Weight History Highest Weight (lbs) Surgery Weight (lbs) Current Weight (lbs) Medical Conditions BEFORE Surgery AFTER Surgery Sleep Apnea Sleep Apnea Diabetes Diabetes High Blood Pressure High Blood Pressure List other medical conditons that have improved: Are you taking fewer medications? Your Weight Loss Journey What was your life like before surgery? (Consider your health, lifestyle, activities, family, etc.)

Your Weight Loss Journey (continued) How did you hear about Barix? --Select One-- Friend Doctor Website TV Print Other How was your experience with Barix Clinics? What is your life like after surgery? (Consider your health, lifestyle, activities, family, etc.)  What would you say to someone considering Barix? 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