You made the decision to take your quality of life to the next level with reconstructive or cosmetic surgery following your weight loss. Now's your chance to share some personal advice that may help someone else.    Please answer each question and send conservative before and after photos. Tight fitting clothing works well for this purpose.  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 TYPE OF RECONSTRUCTIVE/COSMETIC PROCEDURE:   --Select Procedure(s)-- Abdominoplasty-Tummy Tuck Brachioplasty-Arm Lift Mastopexy-Breast Lift Lower Body Lift Liposuction Mammaplasty-Breast Augmentation Thighplasty-Thigh Lift IF OTHER:  SURGERY DATE (MM/DD/YYYY)        WHAT LED YOU TO CONSIDER SURGERY? (Medical problem, clothing, difficulty exercising, self-esteem, etc)

HOW DID YOU RESEARCH THE SURGERY? (Online, friends, consultations, etc)  WHY DID YOU CHOOSE BARIX CLINICS? DESCRIBE YOUR EXPERIENCE? (Consultation, surgery, hospital stay, follow up care) DESCRIBE YOUR LIFE AFTER SURGERY:  (Consider your health, clothing, activities, confidence, etc.)  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