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 severely 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:  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 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) 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 Joint Pain Joint Pain Gout Gout High Cholesterol High Cholesterol List other medical conditons that have improved: Are you taking fewer medications? How did you hear about Barix? --Select One-- Friend Doctor Website TV Print Other Your Weight Loss Journey DESCRIBE YOUR LIFE BEFORE SURGERY (Consider your health, lifestyle, activities, family, etc.)  HOW DID YOU MAKE THE DECISION TO HAVE SURGERY? HOW DID YOU DETERMINE THE SURGERY OPTION BEST FOR YOU?

DESCRIBE YOUR EXPERIENCE WITH BARIX CLINICS: DESCRIBE THE SUPPORT AND FOLLOW-UP CARE YOU RECEIVED: (Post-op visits and phone calls, online support, newsletters/tips, nutrition support, medical support, etc)  DESCRIBE ANY EXCEPTIONAL CARE YOU RECEIVED: (surgeon, nurses, nutritionist, other staff members) HOW IS YOUR LIFE DIFFERENT SINCE SURGERY? (Consider your lifestyle, activities, family, etc.)  HOW HAS YOUR HEALTH BEEN TRANSFORMED BY WEIGHT LOSS?  (decreased medications, improved lab reports, reduced symptoms, improved energy and motility) WHAT CHANGES HAVE YOU MADE TO BE SUCCESSFUL?  (eating habits, exercise, stress management, attitude, therapy, support groups, other) WHAT WOULD YOU LIKE TO TELL SOMEONE CONSIDERING SURGERY? TERMS AND 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. My name in the box below indicates that I have read and agree to the terms above  * required I do not agree to the terms above