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Entrepreneur Contact Form

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Entrepreneurs

Step 1 of 8

This form is used to collect information on prospective ventures. The form will request information on the product, market, financials, team, and your alignment with UCHealth. Although UCHealth frequently becomes a customer after clinical validation, this pipeline is NOT intended for companies interested in only selling their products or services to the hospital. Be prepared to share small amounts of equity, royalties, or both for innovations coming out of this process. Thank you for taking the time to complete the venture pre-screening assessment.
Name of Company*
Provide a 140 character or less twitter description of what your company does*

Company Information
What is the product you wish to co-develop with UCHealth?*
What other products or services do you offer?*
When was the company established?*
Date Format: MM slash DD slash YYYY
How many employees do you have?*

Market
Who are your major competitors?*
What are your value propositions that make you unique?*

Management Team
Executive Member 1
First Name*
Last Name*
Position*
LinkedIn (please include link)
Executive Member 2
First Name*
Last Name*
Position*
LinkedIn (please include link)
Executive Member 3
First Name*
Last Name*
Position
LinkedIn (please include link)
Who is on your Board of Directors?*

Financials
What is your revenue model?*
How many customers do you have?*
What are your sales ($) to date?*

Investment Potential
Are you currently raising venture capital?*
- Yes
- No
Have you had any funding to date? Describe?*

Product & Technology
At what stage is your core product?*
How many locations has your product been deployed?*
If deployed, briefly describe
Have you integrated your product with an EHR? Which ones?*

Contact Information
Email*
Phone
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Comments
This field is for validation purposes and should be left unchanged.