External Intake Form External Intake Form "*" indicates required fields Company Name:* First Name* Last Name* Title* Email* Phone*Company Description:*Company Funding Stage:* Pre-Seed/Seed Stage Series A Series B Series C+ Public Collaboration Opportunity:*Describe your envisioned partnership with UH and/or UH Ventures. Be specific about what you want to achieve. Stage of Product Development: Conceptual Prototype Active research/pilots In market for different use case In market for same or similar use case Please list or describe any current or past activities/relationships with University Hospitals:Non-Confidential Overview Deck or Executive Summary:*PDF preferred. Accepted file types: jpg, gif, png, pdf, ppt, pdf, Max. file size: 16 MB.* I certify that I (i) have the authority to disclose this information, (ii) that the information disclosed is not subject to obligations of confidentiality, (iii) and that this disclosure does not violate any agreement in place with a third party relating to the information. PhoneThis field is for validation purposes and should be left unchanged.