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JourneyLite Appointment Request

Thanks 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!*

Which 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 procedure

We 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 JourneyLite

Your Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Height (ft)*

(for example for 5' 2", enter 5)

Inches*

(for example for 5' 2", enter 2)

Weight (lbs)*

BMI

Preferred Location(s)*

Please 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 resistance

Your 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 pressure

Do 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

Please 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

Not sure

We 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

Unsure

Are you currently pregnant or nursing?*

Yes

N/A

Patients who are pregnancy or nursing are not candidates for weight loss medications.

Do you have a history of drug abuse or addiction?*

Yes

Please 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

Other

Select Procedures of Interest

Spatz Adjustable Gastric Balloon

Orbera Gastric Balloon

Select GERD Treatment Interest(s)

Stretta Procedure

Lap Nissen

Combined Interests

Adipex

Contrave

Gastric Balloon

Gastric Bypass

Gastric Sleeve

Lap Band

Phentermine

Qsymia

Saxenda

SIPS Procedure

WeGovy

Cancel Appointment On

MM slash DD slash YYYY

Insurance/Self Pay:*

If 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 Comments

Cardiac 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 Comments

Gastrointestinal 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 Comments

Do you take any steroids by mouth on a regular basis? (e.g. prednisone, methylprednisolone)*

Please list your steroid regimen:

Additional Message

How did you first hear about us?

Billboard

Friend or Family

Health Fair

Insurance

Internet

Luminary (Surgery Plus & Transcarent)

Magazine

Newspaper

Physician

Radio

Self

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