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Share Your Success - Revision Surgery

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: 

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
IF OTHER:
TYPE OF SURGERY
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
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 read and agree to the terms above
I do not agree to the terms above

                                              

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

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