Bariatric Surgery Feedback Form

Feedback Form

Thank you for letting us be a part of your bariatric surgery journey. Sharing your story is a great testimony to those considering weight loss journey. We look forward to hearing about your experience!
Name*

First NameLast Name
Who Was Your Physician?*
When was your surgery date?*
How many pounds have you lost so far?*
Which are you interested in (you can select more than 1)?*

Filming a short testimonial (we do the filming)Sharing a Before/AfterBeing a model for office filming projects
Briefly describe your previous weight loss attempts and how/why you decided to have surgery*
How has your life/health/mobility/relationship improved since surgery?*
What advice would you give to someone who is considering surgery?*
What has been your greatest non-scale victory?*
E-mail*
example@example.com
Should be Empty: