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Share Your Success

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: 

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
IF OTHER: 
SURGERY TYPE: 
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?

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 health, lifestyle, activities, family, etc.) 

WHAT WOULD YOU LIKE TO TELL SOMEONE CONSIDERING SURGERY?

TERMS AND 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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