First Name *

Last Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Below are questions inquiring about your health history that are required to be answered before the

initial consultation.

Do you have a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome (MENS2)? *

Do you have a personal history of pancreatitis? *

Do you have type 1 or type 2 Diabetes? *

Are you currently pregnant, breastfeeding, or trying to conceive? *

Do you have history of renal failure or any kidney problems? *

Medications offered through our Wellness Program at Willow are currently only FDA approved in patient's with a BMI 30 or greater, or a BMI of 27 or greater with a weight related health condition (High blood pressure, fatty liver, high cholesterol or triglycerides, diabetes). *

I understand

Age: *

How tall are you? *

How much do you currently weigh? *