Idea Submission Form | Applied Medical

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Idea Submission

Title (required)

First Name (required)

Last Name (required)

Which best describes you? (required)
for example: surgeon, nurse, technology licensing officer, medical device company, or independent inventor

Street Address (required)

City (required)

State (required)

Zip Code (required)

Country (required)

Phone (required)

Email (required)

Which hospital are you affiliated with? (optional)

Please select a stage of development for your idea: (required)

Written Concept

Drawings

Prototype

Working Model

Patent Applied For

Patent

Patent Number: (optional)

How would you classify your idea? (required)

An improvement to an existing product or medical device

An improvement to a surgical procedure or technique

A new product or medical device

Other:

Pick the specialty/specialties that your idea could impact: (required)

Cardiac & Vascular Surgery

General Surgery

Urology Surgery

Colorectal Surgery

OBGYN Surgery

Bariatric Surgery

Orthopedic Surgery

Title or Name of your idea: (required)

Description: Please describe your idea and the problem it solves that other currently available products do not solve (required)

Benefits: Please describe the benefits and/or advantages of your idea (required)

Attachments

You may upload up to five files for your idea submission as attachments. Only the following document formats are supported for the upload: .doc, .docx, .txt, .pdf, .ppt, .pptx, .jpeg, .tiff, .png, .gif, .mp4, .mpg, .avi, .flv, .mov. and .qt.

Upload file(s) (optional) * use (Shift + click) or (Ctrl + click) to multi-select files

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