• Customer Agreement
  • New Patient Intake Form
New Patient Intake Form, Customer Agreement

Please fill out and sign both forms. By filling these out and signing, KLTC will be authorized to bill your insurance. Please attach a photo/scanned image of the front and back of the insurance to the intake page.  Give us a call with any questions or issues: Leslie Durbin 269.388.4850 ext: 350. Thank you.

*mandatory fields