The Patient Channel Logo Approval Form

* Indicates Required

First Name*
Last Name:*
Site Address:*
City:*
State:*
Zip:*
Phone Number:	Ext.
Email:*
Where are you using the logos?	Website TV Message System
Site Name:*
Site URL:*

If adding logos to multiple pages, please include the URL of every page on which you are going to put our logos below.

Please indicate below which of the graphic files you will be using by checking the box. NOTE: If you indicate that you are going to be using the GE Healthcare logo, this use must first be approved by GE.