Patient Forms

1-833-24RENAL info@khccares.com

"*" indicates required fields

I am a*

Provider Referring a Patient

New Patient Requesting an Appointment

NOTE: If you are a returning patient, please call 1-833-24RENAL to schedule.

First Name*

Last Name*

DOB*

Phone*

Zip Code*

Preferred Provider

Preferred Location

Reason For Visit

Add Comments

Referring Provider's Name

Referring Health System

Referring Provider's Phone

Referring Provider Email