Today's Date:
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Authorized Submission Number: *
Name:
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Surgery Date:
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Starting Weight:
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Current Weight:
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Are you a patient in Belmond or Des Moines?:
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What made you decide to have weight loss surgery?:
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How long did it take for you to decide to have weight loss surgery?:
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Did anyone either encourage or discourage you from having surgery?:
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What do you wish you'd known before the surgery?:
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What things are you able to do now that may have been difficult or impossible before surgery?:
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Which conditions or diseases have you seen decrease or disappear since your surgery?:
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How has surgery altered your outlook on life, your emotions, and/or relationships?:
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Why did you decide to have surgery with Dr. Eibes?:
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What would you say about Dr. Eibes and his team?:
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What would you tell someone who is considering weight loss surgery?:
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Is there any additional information you would like to share?:
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How would you like your name shared with your testimonial?:
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Would you like to include photos?:
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Upload Before Photo:
Accepted Formats :
Images
Upload After Photo:
Accepted Formats :
Images
Would you be interested in doing a video testimonial?:
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By electronically signing this form, I grant Iowa Weight Loss Specialists and Iowa Specialty Hospital and their employee’s permission to use my photo, filmed image and/or personal testimonial taken on the date indicated below for publicity, educational purposes, website and/or social media (including, but not limited to, Facebook, Twitter and YouTube).
I understand that I will not be paid or receive any reimbursement for the use of my photo, filmed image and /or testimonial. I further give Iowa Weight Loss Specialists and Iowa Specialty Hospital and their employee’s permission to use my name and/or information that was given in accordance with my photo, filmed image and/or testimonial.
Required Signature:
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Email Address:
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Confirm Email Address:
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This needs to match the value of the previous field.
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