Patient Release New Life Bariatric

Share your weight loss surgery success!

To share your weight loss surgery photos and story with our Foothills Weight Loss Surgeons website and social media followers, please fill out the info and our HIPAA Media Release below.
Your Name*

First NameLast Name
I grant permission for Foothills Weight Loss Surgeons to use photos that I have posted on the private Foothills Support Group Facebook page for the Foothills website & social media.*

YesNo
I prefer to email my Before & After photos directly to Foothills Weight Loss/Premier Surgical Marketing. (Please email photos to koneal@premiersurgical.com)

YesNo
Tell Us About Your Weight Loss Surgery Journey
Which bariatric procedure did you have?*

Gastric SleeveGastric BypassBPD/ DSSADIOther
Bariatric Surgery Date?

MonthDayYear
Date
Your highest weight before beginning the Foothills Weight Loss program?
Current Weight?
What weight-related health issues did you have before your surgery?*
How have your health and quality of life changed since your surgery?*
Advice for those considering weight loss surgery?
Premier Surgical Associates Patient HIPAA/Media Release
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail
example@example.com
I, First Name Last Name , (Patient Name) hereby authorize Premier Surgical Associates, LLC, to use certain protected health information (PHI) about me. Specifically, this authorization permits you to use the following PHI about me:
- Name, age, description of medical condition and treatment, photo and/or video image
The information in this authorization is to be used or disclosed for the following purpose:
- Patient testimonial article and/or video
- Patient before & after results on Practice website, social media, and advertisements
I understand that my information may not be protected from re-disclosure one it has been released pursuant to this authorization.

I understand that my treatment will not be conditioned on signing this authorization.

I understand I have the right to revoke this authorization by written notification to Premier Surgical Associates, PLLC, to which this authorization is submitted. Premier Surgical will comply except to the extent that the provider has already acted in reliance upon this authorization.

This authorization will expire 10 years from enacted date.
Patient or Personal Representative Signature*
Date*

MonthDayYear
Date
Should be Empty:

Share your weight loss surgery success!

Tell Us About Your Weight Loss Surgery Journey

Premier Surgical Associates Patient HIPAA/Media Release