Thank you for showing interest in our Wellness Program here at Willow! Please complete the following screening form to help us determine initial safety and what your goals are. We will be notified of your form submission and will reach out to you with more information!

First Name *

Last Name *

Email *

Phone *

What are you most interested in? *

Weight Loss: GLP-1 peptides

Microdosing: GLP-1 peptides

I’m not sure?

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 customized to each patient. They may be prescribed for weight loss or for different wellness reasons. A BMI requirement may apply. *

I understand

Age: *

How tall are you? *

How much do you currently weigh? *

What are your current wellness goals? *

If weight loss is a goal, what is your estimated goal weight? (We do encourage non-scale goals as well. If weight loss is not a goal, type NA below) *