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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 a free consultation to discuss surgical procedures, gastric balloon, and weight loss medications.

If you're not yet ready to make an appointment and just have questions, use our contact form!

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 prior to your consultation. There are no financial (or any other) obligations from submitting the form!

We have 5 office locations throughout Ohio, Kentucky, and Indiana to serve you, and we can do virtual appointments for many visits.

Please select the program(s) in which you are most 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

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

I'd prefer not to receive texts

Phone

Your address isn't mandatory, but it is helpful to us.

Address:

Street Address City State ZIP Code

Height (ft - e.g. 5'0 enter a 5)*

Inches (e.g. 5'0 enter a 0)*

Weight (lbs)*

BMI

Preferred Location:*

PLEASE SELECT A LOCATION OTHER THAN "VIRTUAL!"

State law requires a live, in-person initial consultation to start weight loss medications. You may be eligible for virtual visits for refills.

Weight loss medication interest(s):*

Adipex (phentermine)

Contrave

Qsymia

Tenuate (diethylpropion)

GLP-1's (injectables)

Unsure (or other)

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.

Additional Message

How did you first hear about us?

Billboard

Employer

Friend or Family

Health Fair

Insurance

Internet

Magazine

Newspaper

Physician

Radio

Self

By 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.

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