Save $1000!08/05/2019 by DrCurryFor a limited time, take $1000 off select self-pay weight loss surgery procedures!Choose your option!Gastric Sleeve SIPS Gastric Bypass Lap Band Gastric Balloon *Excludes all revisional procedures except band-to-sleeve, band-to-bypass and sleeve-to SIPS.Appointment RequestRequest an appointment here!"*" indicates required fieldsStep 1 of 100%JourneyLite Appointment RequestThanks for your interest in JourneyLite, your trusted partner for medical and surgical weight loss! This form will collect the information we need in order to schedule an appointment for the program of your interest. After completing and submitting the form, you will receive a callback from one of our patient service representatives who can answer any questions you may have. There are no financial (or any other) obligations from submitting the form!Appointment Interest-Please select the program(s) in which you are interested!*Surgical Weight LossRevision of Prior Weight Loss SurgeryGastric BalloonMedical Weight Loss (Adipex, WeGovy, etc)Combination Surgical & MedicalCancel AppointmentWhich procedure(s) have you had in the past? Gastric bypass or VBG (stomach stapling) Gastric band Gastric sleeve Duodenal switch ESG (endoscopic sleeve gastroplasty) SIPS, SADI, or LDS procedureWe do not offer surgical revisions for this procedure due to increased risk and poor long-term results. Medication treatment options are available, however. Please change "Appointment Interest" above to "Medical Weight Loss" if you are interested in proceeding!Your Name* First Last Your Email* Enter Email Confirm Email Date of Birth* MM slash DD slash YYYY Age*Phone*At some point we may need to text you appointment reminders or other important information. By providing your phone number, you agree to receive text messages from JourneyLite. Message & data rates may apply. Message frequency varies, we try to keep it to a minimum. Reply STOP to any message to opt out, reply HELP for help. Click here for our Terms & Conditions or our Privacy Policy.Permission to Text/SMS I agree to receive texts/SMS from JourneyLiteYour Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Height (ft)*(for example for 5' 2", enter 5)Inches*(for example for 5' 2", enter 2)Weight (lbs)*BMIPreferred Location(s)*CincinnatiColumbusDaytonNorthern KyVirtualPlease note that we require a live, in-person initial consultation to start weight loss medications. In most cases, after the initial appointment, you can do virtual appointments, however every third appointment must be live.Your BMI is too low for initiation of treatment with weight loss medications. Ohio requires a BMI over 27.Your BMI is too low for initiation of treatment with weight loss medications. Kentucky requires a BMI over 25, and Ohio requires a BMI over 27.Are you currently being treated for any of the following issues?* I have none of these issues Fatty liver High cholesterol or triglycerides High blood pressure Major depression Polycystic ovary Sleep apnea Type 2 diabetes, pre-diabetes, or insulin resistanceYour BMI is too low for initiation of treatment with weight loss medications. Ohio requires a BMI over 30, or a BMI of 27-30 with weight-related medical conditions.Your BMI is too low for initiation of treatment with weight loss medications. Kentucky requires a BMI over 27, or a BMI of 25-27 with weight-related medical conditions.Have you had any of these issues in the past?* I have had none of these issues Glaucoma Heart attack Heart surgery or stent Irregular heart beat or atrial fib Seizures Stroke Uncontrolled high blood pressureDo you currently take any of the listed medications below?* I do not take any of these Adderral (dextroamphetamine) Focalin (dexmethylphenidate) Ritalin (methylphenidate) Vyvanse (lisdexamfetamine) Subutex/Suboxone (buprenorphine) Vivitrol (naltrexone)Weight loss medication interest(s):* Adipex (phentermine) Contrave Qsymia Tenuate (diethylpropion) Wegovy/Saxenda/Mounjaro/Ozempic Unsure (or other)Do you currently take any INJECTABLE medications for diabetes?* Yes NoPlease note that diabetics who already take injectables are not candidates in our program for GLP-1 RA's such as Wegovy (semaglutide) or Mounjaro.Have you received a prescription for an appetite suppressant from any provider within the last 3 months?* Yes No Not sureWe require a minimum medication-free break of 3 months before re-starting treatment.Have you seen us for medical weight loss in the last 12 months?* Yes No UnsureAre you currently pregnant or nursing?* Yes No N/APatients who are pregnancy or nursing are not candidates for weight loss medications.Do you have a history of drug abuse or addiction?* Yes NoPlease note that a state-required controlled substance report will be reviewed prior to prescribing any medications. Any false or misleading statements regarding medical conditions, substance abuse history, or recent prescriptions for weight loss medications could result in a permanent ban based on Ohio and Kentucky regulations.According to the State Medical Boards of Ohio and Kentucky, patients with a current (or past) history of any type of substance abuse disorder are not eligible for weight loss medications.You may not be eligible for weight loss medications based on your medical history. Your information will be reviewed and a team member will be in contact with you.You may not be eligible for weight loss medications based on your current medications. Your information will be reviewed and a team member will be in contact with you.Select Procedures of Interest Gastric Sleeve Gastric Bypass Lap Band SIPS/SADI OtherSelect Procedures of Interest Spatz Adjustable Gastric Balloon Orbera Gastric BalloonSelect GERD Treatment Interest(s) Stretta Procedure Lap NissenCombined Interests Adipex Contrave Gastric Balloon Gastric Bypass Gastric Sleeve Lap Band Phentermine Qsymia Saxenda SIPS Procedure WeGovyCancel Appointment On MM slash DD slash YYYY Insurance/Self Pay:*Self-payUnsureAetna AmbetterAnthemAetnaBuckeyeCaresourceCignaHumanaHumana MedicareMediblueMedical MutualMedicareMedicaid (Oh/Ky/In)MedigoldMolinaParamount AdvantageSurgery PlusTranscarentUHC Community PlanUHC MedicareUnited HealthcareOtherIf you are going through insurance, select your company from the list. If you are unsure about your coverage, select "Unsure." If you know you're insurance doesn't cover surgery, select "Self-pay."Currently we are not accepting this plan, please check back in the future! If you are a self-pay patient, please proceed.Pulmonary History* I have never had any of these problems. Blood clot to lungs (pulmonary embolism) Emphysema COPD Other pulmonary issue (please explain below)Check any issues that you currently have, or have had in the past.Pulmonary CommentsCardiac History-Check all that apply!* I have never had any of these problems. Chest pain/angina History of heart surgery History of heart stent or angioplasty Previous heart attack Other cardiac issue (please explain below)Check any issues that you currently have, or have had in the past.Cardiac CommentsGastrointestinal History* I have never had any of these problems. History of Crohn's disease History of cirrhosis History of surgery for hiatal hernia (Nissen fundoplication) History of any other type of hernia repair (please explain below) Other abdominal surgery (please list below)Check any issues that you currently have, or have had in the past.Gastrointestinal CommentsDo you take any steroids by mouth on a regular basis? (e.g. prednisone, methylprednisolone)*YesNoPlease list your steroid regimen:Additional MessageHow did you first hear about us? Billboard Friend or Family Health Fair Insurance Internet Luminary (Surgery Plus & Transcarent) Magazine Newspaper Physician Radio Self TVBy clicking the "Submit Your Appointment Request" button, you give permission for this information to be transmitted via internet to JourneyLite Surgery Center and JourneyLite Physicians.CommentsThis field is for validation purposes and should be left unchanged.Δ