Idea Disclosure Form

The purpose of the Non-Disclosure Agreement (NDA) is protect all participating parties and all related intellectual property.
The purpose of the Idea Disclosure Form is to get an understanding of your concept and invention for us to determine an initial appraisal.

Before proceeding please read our non-disclosure agreement here:
Please see a sample of a completed Idea Disclosure Form here:

Please indicate that you have read and agree with the terms of the above non disclosure agreement:*AgreeIdea Name*Title, Name*Address*Email*Contact Number*Inventor Clinical Specialty
Hospital / InstituteInventor BackgroundAre there any other parties, promoters, or business partners involved?YesNoIdentify by nameHas any funding, such as grant or investment, been secured for this idea?
Has your idea been patented (freedom to operate)? If so, please provide details.
Individual/Company Website
Lead Contact Email*Date idea disclosed to i360medical*What is the idea?*Intended use?*

Clinical Specialty of the idea? (Mark all that apply)*
Anaesthesiology
CancerCardiovascular
ChemistryDentalDermatology
Ear, Nose, and Throat
Emergency Medicine
Gastroenterology and Urology
General Surgery
Haematology
Immunology
Microbiology
Neurology
Obstetrics and Gynaecology
Ophthalmic
OrthopaedicPathology
Paediatrics
Physical Medicine/Rehabilitation
Radiation Medicine
Radiology
Toxicology

OtherIntended Patient(s)*

Where and in what situation is it used?*
HospitalOperating RoomGP ClinicPrimary Care CenterAt home

What does it look like?Is the solution?Single use (disposable)ReusableResponsible (partly disposable)How did you come up with the idea or what inspired it?*
Please list the titles and dates of any publications relevant to the idea made by you or other parties, including presentations at conferences, publications on websites etc.*What unmet need or problem does the idea propose to address/solve?*
What are the novel features of your idea compared to existing solutions?*
Who does it propose to help?*
What are the specific advantages of your idea compared to existing solutions*Do you think there is a clinical need for this idea? Why?*
Do you think there is a need or a place in the market for this idea? Why?*Is there an alternative to your idea currently available?
Are you aware of any (i) publications or (ii) patented ideas that describe something similar to your idea. Reference www.google.com/patentsDo you think the idea is technically feasible? Why?
Is the idea easy to use/intuitive or does it require special training/expertise?
What price would you be willing to pay for this idea if it were on the market?
What assistance do you need from i360medical?*
Any other comments?

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