Request

This webform is intended for US Healthcare Professionals only.

To report a suspected side effect, adverse reaction, or concern about the quality of a GEHC Product
contact GEHC PDx Pharmacovigilance at 800-654-0118 (option 2, option 1) or email
Gpv.DrugSafety@gehealthcare.com. Do NOT submit on this medical inquiry form.

GE HealthCare Product

Request Type

Please enter your contact information.

Professional Designation

HCP Name

HCP Email

Facility/Affiliation

Phone/Extension

Department

Address

City

State

Zip

Query submitted by Sales

Medical Affairs Request: The following must be completed using the Requestor's own words and/or with the Requestor's consent.

Describe the specific information requested

Signature of HCP

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Sign name using mouse or touch pad

Signature of

The completed form will be provided to your Medical Affairs Representative and will be included as part of GE Healthcare’s record of the healthcare provider interaction.

MedPDx-00279 August, 2024

REQUEST TO GEHC MEDICAL AFFAIRS

Please enter your contact information.

Medical Affairs Request: The following must be completed using the Requestor's own words and/or with the Requestor's consent.