White Glove Services Onboarding Form

Please complete all fields and submit.

Site Name *

Site Code *

Site Address

Address 1 *

Address 2

City *

State *

Zip Code *

Shipping Address

Address 1 *

Address 2

City *

State *

Zip Code *

Ship Attention To: *

Contract Start Date

Credentialing system in use?

Site Access

Is a hospital orientation required for our team? *

Yes

No

Work Area(s)

Identify location of physical work area for PMs. *

Identify location of physical work area for repairs. *

Accessible Network for InfuSystem Team

Network Name *

Network Password *

Will GE be providing out of scope parts and accessories? *

Yes

No

Are there current plans to update the fleet at this site? *

Yes

No

Month and Year of Planned Update

What is the current version of software being used on the primary infusion device at this site? *

Contact Information

First Name *

Last Name *

Title *

Email Address *

Phone Number *

GE Day 01 Contact *

Yes

No

Access to DeviceHub Required? *

Yes

No

Add another contact +

Contact #2

First Name

Last Name

Title

Email Address

Phone Number

GE Day 01 Contact

Yes

No

Access to DeviceHub Required?

Yes

No

Add another contact +

Contact #3

First Name

Last Name

Title

Email Address

Phone Number

GE Day 01 Contact

Yes

No

Access to DeviceHub Required?

Yes

No

Add another contact +

Contact #4

First Name

Last Name

Title

Email Address

Phone Number

GE Day 01 Contact

Yes

No

Access to DeviceHub Required?

Yes

No

Add another contact +

Contact #5

First Name

Last Name

Title

Email Address

Phone Number

GE Day 01 Contact

Yes

No

Access to DeviceHub Required?

Yes

No