Share an Idea

Name (required) Middle Initial Title Cellphone Work phone (required) Email (required) Home Address City State Zip Please List all facilities with whom you are associated (required)

Facility Address

Facility Address 2 Facility City Facility State Facility Zip Describe your problem/idea (required) For example: I would like to solve the problem of needle injuries when withdrawing medications from vials. Another example: I would like to solve the problem with Endoscopy Camera Lens that gets foggy when removing from the trocar and reinserting it

Please provide any existing similar solutions that are deficient (required) What medical area is your problem/idea is related to (O.R. Anesthesia, etc.) Please share with us any solution. This can be with writing a sketch or a prototype if available (by mail)

Non-Disclosure Agreement

The undersigned hereby acknowledges receipt of the within disclosure, comprising the documents data and drawings and other materials appended hereto, in confidence from (hereinafter referred to as ‘DISCLOSER’). It is understood that said disclosure is being made to the undersigned by DISCLOSER in order to allow the undersigned to evaluate the same for purposes of entering into negotiations whereby the undersigned or his company or employer may acquire a right from DISCLOSER to utilize the same in commercial activities of the undersigned or his company or employer. If is further understood that if no written agreement is entered into between DISCLOSER and the undersigned to the contrary, that the undersigned agrees to keep said disclosure in confidence and not to voluntary disclose to any other person, company, agent of the United States, or foreign government, or concern, the information contained in the within disclosure which is being received by the undersigned only for the purposes set forth above.

The undersigned may disclose this information to third parties of developing this information but only after the third party signed similar Confidence Disclosure Agreement with the undersigned.

It is understood that DISCLOSER is to be compensated for the use of any said discloser and that the undersigned agrees not to make use of the information included in said disclosure without obtaining the prior written approval thereof from DISCLOSER, provided however, that the undersigned is not prevented from, nor liable for, use of subject matter of said matter of said disclosure of same:

is disclosed by the undersigned to others after two (2) years from the date of his agreement; or
was in the public domain at the time it was disclosed to the undersigned; or
in disclosed or comes into the public domain during the period of two (2) years after the date hereof as a result of actions by any party other than the undersigned; or
Advanced Medical Innovations has a similar project in process and/or the information submitted is already known

Once submitted we will email you a hard copy with our signature and ask you to sign it as well and return to us by email or email.