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Heart Health Screening Request Form

As your indispensable healthcare partner, Hendricks Regional Health is committed to providing you with life-saving health screening opportunities at a low price. Please fill out the form below so that we may recommend the screening that would be most beneficial to you.

Use this form to request a $49 Heart Scan.

Results are provided to both you and your primary care doctor. If you don’t have a family physician, we are happy to help you find one that meets your needs. Health insurance plans do not cover these screenings. Once you have submitted the form, we will contact you within 5 business days to schedule and arrange payment.

Your Basic Information

Name*

First Name

Last Name

Date of Birth*

Daytime Phone Number*

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Are you a public safety employee working in Hendricks or Putnam counties (first responder, law enforcement professional, or healthcare worker at Hendricks Regional Health)? We offer a Public Safety Worker Heart Scan Fund providing complementary heart scans to qualifying individuals. If you answered yes, please bring your employer-issued ID to your heart scan appointment.

Yes No

Heart Health Screening Request Form

Your Basic Information

Medical Questionnaire

Schedule Your Scan