First Name

Last Name

Address Line 1

Address Line 2

City

State / Province

Zip Code

Phone

Email address

Investment Experience:

Are you an accredited investor as defined by SEC regulations?

Have you invested in medical technology companies before?

What is your typical investment range?

Risk Tolerance:

How would you rate your risk tolerance for early-stage investments?

Investment Horizon:

What is your expected investment timeline?

Industry Knowledge:

Rate your knowledge of the medical device industry:

Are you familiar with FDA regulatory processes for medical devices?

Additional Information:

Are you interested in taking an active role in the company (e.g., advisory board)?