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 Weight History   Highest Weight (lbs) Surgery Weight (lbs) Current Weight (lbs) Weight lost in first year Dress/pant size at surgery Dress/pant size now Height (inches) Current Age Check those that apply: I am emailing before & after pictures I am mailing before & after pictures Deciding On Barix   What factors helped you choose to have surgery at Barix Clinics? Private Facilities Experienced Surgeons Large Volume of Surgeries Performed Aftercare Program Dietitians / Nutritionists Support Groups Reading Other Patient's Stories Your Barix Experience How was your experience in these areas? (Feel free to elaborate if you have a special story to tell.) Your contact with the Patient Service Reps: Your experience at the initial consultation: Your contact with the insurance group and the pre-approval process: The surgery itself: Your hospital stay (include the facilities, quality of care, family's experience, nutrition education): Your follow-up care (include support groups and group practice experiences):

Medical Conditions BEFORE Surgery AFTER Surgery Sleep Apnea Sleep Apnea Diabetes Diabetes Joint Stiffness or Pain Joint Stiffness or Pain Congestive Heart Failure Congestive Heart Failure Infertility Infertility High Blood Pressure High Blood Pressure Arthritis Arthritis GERD -Reflux Disease GERD- Reflux Disease List other medical conditons that have improved: Are you taking fewer medications? What lifestyle and eating habits have you changed? How has bariatric surgery changed your life? How did you hear about Barix Clinics? Did you consider other hospitals?  Why did you choose Barix? What would you say to someone considering Barix? Terms: I agree and authorize the use, publication, broadcast, and copyright of photographs that I have provided or that Barix Clinics takes of me and any information contained in this Patient Questionnaire or subsequently provided by me for any publicity, advertising, communications, or sales promotion purposes, alone or in conjunction with other material, in whole or in part by Forest Health Services, LLC; its parent and affiliated companies ("Forest"). By agreeing, I release Forest, its officers, directors, employees, representatives, agents, and assignees, from all claims for damages for defamation, invasion of privacy, or any other claim arising from the use of my name, information, quotations, photographs, and the like. And, I expressly authorize Forest Health Services to call or email me in the future. I have read and agree to the terms above I do not agree to the terms above