Keep the Beat Prequalification

Thank you for your interest in scheduling a Keep the Beat appointment. Please complete the questionnaire below to confirm you're eligible.

Name

First Last

Are you over the age of 30?(Required)

Yes

No

Have you been diagnosed with coronary artery disease, had bypass surgery or stents placed?(Required)

Yes

No

Do you weigh less than 500 lbs?(Required)

Yes

No

Have you gone through Keep the Beat in the last five years?(Required)

Yes

No

Yes, but I have a referral from my primary care provider

Are you an established patient with Arkansas Heart Hospital?(Required)

Yes

No

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Arkansas Heart Hospital
1701 South Shackleford Rd.
Little Rock, AR 72211
(501) 219-7000