Please provide the following information:

First Name			Last Name
Age			Gender
Preop Weight			Current Weight
Surgery Date			Surgeon
Home Phone			Work Phone
E-mail

Please briefly describe your life before surgery (200 words or less).

Please briefly describe your life after surgery (200 words or less).

Please provide a low resolution preoperative picture of yourself.*

Please provide a low resolution postoperative picture of yourself.*

*Photos should be 30k or less and in .jpg or .gif formats only.  Prior to submitting your photographs, please name them with your first and last name so we will be able to attach the right pictures to the right story.

Additional Comments:

I give U.S. Bariatric permission to use my story and photographs in the Patient Profile section of the Silhouette newsletter. 

I understand that my story and pictures may or may not be used in the Silhouette.

I understand that I may or may not be notified that my story and pictures will appear in a future edition of Silhouette.