KTA Health+ Program Inquiry Form
Thank you for inquiring about our KTA Health+ Program! Please fill out the following form so we may direct you to the appropriate class. Our different classes focus on either diabetes prevention or management. Upon completion, our staff will reach out to you via phone or email.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Other
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you ever been diagnosed with Type 1 or Type 2 Diabetes? (excludes Gestational Diabetes)
*
Yes
No
Back
Next
You may qualify for the Diabetes Self Management Education Program (DSME)!
This program is for those who have already been diagnosed with Type 1 or Type 2 Diabetes. It is a 9 week program that teaches you how to manage your diabetes.
The DSME Program requires a referral from your doctor which KTA Pharmacies can request. Are you interested in participating in this program and do you authorize KTA to request the referral on your behalf?
*
Yes
No
Name of your Primary Care Doctor
*
Phone Number of Primary Care Doctor
*
Please enter a valid phone number.
What was your most recent A1c?
If unknown, please leave blank.
How did you hear about our Diabetes Education classes?
Please Select
Social Media
KTA Super Stores website
KTA Pharmacy Location
Primary Care Provider
Past KTA DSME participant
Flyers
Newspaper Ad
Other
Insurance carrier
Back
Next
You may qualify for the Diabetes Prevention Program (DPP)!
This year-long lifestyle change program is for those with prediabetes that would like to learn more about healthy habits and changes they can make to reduce their risk of developing Type 2 Diabetes.
DPP is a year-long program taught by a certified lifestyle coach. Are you interested in participating in and learning more about this program?
*
Yes
No
What is your current height and weight? This will be used to calculate your BMI to verify eligibility for the DPP program.
*
What was your most recent A1c?
If unknown, please leave blank.
How did you hear about our Diabetes Prevention Program class?
Please Select
Social Media
KTA Super Stores website
KTA Pharmacy Location
Primary Care Provider
Past KTA DPP Participant
Flyers
Newspaper Ad
Other
What is your Primary Care Provider's Name?
If willing, please share the name of the past KTA DPP participant that you heard about this program from
Insurance carrier
Back
Next
Feel free to ask us any questions about our diabetes programs. Type your question below:
Submit
Should be Empty: