(501) 748-8000 PATIENT PORTAL FIND A DOCTOR ABOUT PROCEDURES FOR PATIENTS & VISITORS BLOG CONTACT REQUEST AN APPOINTMENT REFER A PATIENT REFER A PATIENT To refer a patient to Arkansas Surgical Hospital, please fill out the form below. Name* I am a I am a* Select Please Prospective / Current Patient Family / Relative Friend Physician How did you hear about Arkansas Surgical Hospital? How did you hear about Arkansas Surgical Hospital?* Family / Friend Former Patient Internet / Website / Email Knowledge Physician / Medical Professional Radio Television US News and World Report Other Phone* Email* Mailing Address City* State Please select a state. Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont\ Virginia Washington West Virginia Wisconsin Wyoming ZIP CODE Has the patient had an evaluation or diagnostic testing within the last 6 months? Yes No Has a physician told the patient that surgery is needed? Yes No Date of Birth MM slash DD slash YYYY Condition/Symptoms Area/Location of Condition Patient's Insurance Plan Other Insurance NEED HELP SCHEDULING AN APPOINTMENT WITH A SURGEON? REQUEST AN APPOINTMENT MORE QUESTIONS? CONTACT MAIN LINE (501) 748-8000 TOLL-FREE NUMBER (866) 273-1271 VISIT THE HOSPITAL 5201 Northshore Drive North Little Rock, AR 72118 USE THE BILL PAY SYSTEM ONLINE BILL PAY Mission Vision Values ABOUTCONTACTPROCEDURESREFER A PATIENTFOR PATIENTS & VISITORSPATIENT PORTALBLOGCAREERS © 2021 Arkansas Surgical Hospital. All Rights Reserved. Notice of Non-Discrimination | Notice of Privacy Practices