IQ Medical Ventures B.V.
WTC Rotterdam
Beursplein 37, Suite 1960
3011 AARotterdam
TheNetherlands
Tel+31 10 2619100
Fax+31 15 8901777
TO BE FILLED IN BY
IQ Medical Ventures B.V.
FILE NUMBER: ......
MEDICAL INVENTION SUBMISSION FORM
You can have your invention evaluated by IQ Medical Ventures B.V.. The invention must be related to a new medical product or process/procedure. Please, fill out the following in a legible fashion, and if applicable please addattachments. Send the form to IQ Medical Ventures B.V., P.O. Box 30192, 3001 DD ROTTERDAM, The Netherlands or scan it and e-mail it to .
It is advisable to make copies of the form before sending.
Name and initials:M/F ......
Address:......
Postal code + city:......
Country:......
Telephone:......
Fax:......
E-mail:......
Date of birth:......
Education:......
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Profession:......
QUESTIONS ABOUT THE INVENTION:
- What is the name of your invention?
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- Briefly describe your invention. At question 10 you can give an extended description.
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- What problem does your invention solve?
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- For whom is your invention intended (target group)?
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- Which markets or companies might be interested in your invention?
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- Are you familiar with similar existing solutionsfor the problem in question?
0 yes0 no
If yes, please describe the other solutions and name the advantages of your idea over these other solutions.
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- At what stage is your invention? (please mark with a cross)
0 idea0 prototype0tested
- Have you already applied for a patent or have you otherwise sought protection for your invention? Please attach copies of all relevant documentation.
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- Have you contacted other institutions or companies in connection with your invention?
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- Give a detailed description of your invention, including (but not limited to) experience in practice or descriptions of research activities. We would like to receive this information in attachments. The attachments should be numbered, not bound or stapled, and marked with the name of the submitting party on the reverse side. If relevant you can send prototypes, pictures or a video.
The undersigned has conceived the invention described in this submission form as a private individual,and requestsIQ Medical Ventures B.V. to evaluate this invention (in accordance with the terms and conditions maintained by IQ Medical Ventures B.V..)
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