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Intake form

Please provide below information. This information will be used to evaluate if Health Innovation Netherlands can offer you the support you are looking for. All information provided is kept confidential, will not be used for any other purposes and will not be shared with any third parties.

Innovator name

The name of the person, company, institute or any other entity making the claims.

Contact name

Contact e-mail

Contact phone

Product name

A short, catchy name of your product or prototype, enabling us to easily identify you.

Brief product description

Please describe at least the intervention, target population and the setting, e.g. primary care, hospital care.

What is your primary claim?

What is the health issue you’re trying to solve? What are the advantages of your innovation? Why is your innovation superior to alternatives?

What is the current technical and clinical status of the product?

Briefly describe (clinical) studies conducted or planned, and the current technical and clinical status of the product, including target market entry.

Are you or your organization the owner of (key components of) the innovation?

Feel free to answer with 'yes' or 'no', or elaborate if needed.

What are your main questions to HI-NL?

Does a working prototype exist?

Yes

Has the product already received CE marking?

Yes

How do you anticipate to fund your HI-NL Track?

Health~Holland call

KWF call

Private

Other…

In case you applied or intend to apply for funding from Health~Holland or KWF, what is the name of the call?