Name *

First Name

Last Name

Mobile Phone

(###)

###

####

Business Phone

(###)

###

####

How would you describe your type of clinical practice? *

University | Academic

Community with hospital affiliation

Community without hospital affiliation

Which of the following best describes your interest in evaluating healthcare startups? *

I prefer to be presented with companies that have already been vetted by others.

I prefer to be involved in the vetting and due diligence of companies.

How many hours per month would you be willing to contribute to assisting with due diligence on startups in which you are interested? *

<5 hours

5-10 hours

10-15 hours

15-20 hours

20 hours+

What are the types of healthcare startups in which you are interested in assisting? *

Please choose all that apply.

Digital health

Medical device

Pharmaceutical/Therapeutic

If interested in being an advisor, at what capacity can you help the startups in your portfolio?

Choose all that apply.

Healthcare industry introductions

Defining product market fit

Product development

Pilot site for new products

Clinical trials introductions

Access to patients

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