Image Request Form

Image Request Form

Requestor information

Before submitting your request, please complete our Image & Video Licensing Agreement and attach a signed version via the form below.

Image & Video Licensing Agreement

Description of purpose


News/magazine articleJournal ArticleProfessional PaperTextbook/book chapterPresentation/PowerpointTV newsVideoPress releaseStudent projectPatient educational materialClinician educational materialWebsiteBlogOther




Image(s) Request



Requirements for Permission to Use SynCardia Images

By completing the form above, you are making a request to use copyrighted material owned by SynCardia Systems, LLC, and agree to abide by the conditions set forth below in connection with the use of any and all material provided to you by SynCardia.

  • The following courtesy line will be included with the images(s) provided by SynCardia:
    Courtesy of syncardiastage.wpengine.com
  • None of the requested images or video shall be used beyond the scope described above or in a disparaging manner against SynCardia, any SynCardia representative, SynCardia product or SynCardia customer.
  • SynCardia reserves the right to revoke any authorization if the purpose of use is found to conflict with SynCardia’s policies, to violate the law, to be inappropriate as determined by SynCardia or be used beyond the scope described above.
  • When possible, requestor will provide SynCardia with a copy of, or link to, the final product within two weeks of publication.

I, (please enter your full legal name), verify that the information I have submitted is true and accurate, and that I have read, understand and agree to the Requirements for Permission to Use SynCardia Images.