Client Portal - Willow Wellness Center

Appointment Request

Welcome to Willow Wellness Center

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Please select a Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If this is a life-threatening emergency, please call 911.

Insurance:

Insurance Company Name:

Member #:

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Appointment Request

Welcome to Willow Wellness Center

Personal Information

First Name:* Middle Name: Last Name:* Date of Birth:* Gender of Legal Record:* Male Female

Contact Information

E-mail:*

Phone

Type:*
Number:*

Address

Type:* Street Address: Line2: City: State:
Zip Code:

Please Select a Provider:

Please explain the reason you are seeking help at this time:

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

Insurance

Insurance Company Name: Member #:

Submit

Cancel

Clinic Address

1400 Renaissance Drive Suite 401
Park Ridge, 60068-1337

Billing Address

1400 Renaissance Drive Suite 401
Park Ridge, IL 60068-1337

Clinic Phone No.

Billing Phone No.

(847) 318-8200

Business Hours

8 a.m. to 8 p.m., Monday through Friday. 8 a.m. to 3 p.m., Saturday. Closed Sunday.