Pre-Registration / Cardiac Screening

Anthony Bates Foundation

Pre-Registration / Cardiac Screening

This is to Register YOU

/or /

/ your family member /

for our Cardiac Screenings in 2008

Heart Screening Program at various

locations including the Anthony Bates Foundation

office and other Arizona locations.

The Anthony Bates Foundation offers

CARDIAC SCREENINGS for a tax deductible

donation. Tests include ECG, Echocardiogram,

blood pressure & cardiac questionnaire

for any age that are interested.

Please help us continue our mission!

Have your heart screened for peace of mind!

Make an appointment today!

PreRegister Today!!

* no age restrictions for In Office Low Cost Heart Screenings

Last Name
First Name
Parents Last Name
Parents First Name
Gender	Male
Gender	Female
Field of Work
Appointment Date
Preferred Appointment Time
Email Address
Home Address
Telephone
Comments or Questions

Donations can be accepted on-line or

at the time of your Heart Screening!

Donate for your Low Cost Screening

Use your Credit Card

Student Discount

$ 50.00 suggested donation

Special:

Firefighters &

Gov't Workers

$ 65.00 suggested donation

Suggested Full Amount

$ 75.00 suggested donation