BH Screening Questionnaire

Screening Questions: Determine if you are eligible for this free cardiac screening test.
Consent: For those who meet the screening requirements, review and sign the Informed Consent.
Application: For those who meet the screening requirements and sign the consent, complete the application.
Scheduling: After your application information is completed and insurance verified, you will be sent an email within 7 to 10 business days to schedule your appointment.

First Name *

Middle Name

Last Name *

Email (One email address for each application) *

Date of Birth *

Phone # *

Street Address *

City *

State *

Zip Code *

Bus Ad

Event

Family Member or Friend

Mailer

Media (TV, radio, newspaper)

Physician or Medical Professional

Social Media

Website

How did you hear about the Broward Heart Project?*