Appointment Request "*" indicates required fields InstagramThis field is for validation purposes and should be left unchanged.Request a consultation. Please provide only the information needed for our patient service team to contact you. Do not include detailed medical information in this form.First Name*Last Name*Mobile Phone*Email* We will send a confirmation to this address.State*Please selectOhioIndianaKentuckyMichiganIllinoisWisconsinWest VirginiaMissouriTennesseePennsylvaniaAnother statePreferred Location*Please selectCincinnati / EvendaleColumbus / Grove CityDayton / MoraineNorthern Kentucky / Crestview HillsIndianapolis / GreenwoodVirtual consultationNot sureProgram(s) of Interest:* Weight loss surgery Gastric balloon Medications General surgery (e.g. gallbladder) Other Preferred Contact Method* Call Text message Either call or text Best Time to Contact You*Please selectWeekday morningWeekday afternoonAnytime during business hoursOptional MessagePlease do not include diagnoses, medication lists, test results, or other detailed medical information.Contact and Privacy Acknowledgment* I agree that JourneyLite may contact me about this request by phone, text message, and email, including through automated technology. Consent is not a condition of receiving services. Message and data rates may apply. Reply STOP to opt out of texts. I also acknowledge the JourneyLite Privacy Policy and understand that this form is not for emergencies or urgent medical concerns. Review the JourneyLite Privacy Policy. Prefer not to provide electronic contact consent? Call JourneyLite at (877) 442-2263. For a medical emergency, call 911.Submitting this form does not guarantee eligibility, establish a physician-patient relationship, or obligate you to proceed with treatment. Individual candidacy is determined after consultation and medical evaluation.
