Appointment Request "*" indicates required fields URLThis 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 Permission* 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. Prefer not to provide electronic contact consent? Call JourneyLite directly at (877) 442-2263.Privacy Acknowledgment* I acknowledge the JourneyLite Privacy Policy and understand that this form is not for emergencies or urgent medical concerns. Privacy Policy: review the JourneyLite Privacy Policy. 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.