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New Product Evaluation Questionnaire

Thank you for submitting your new product(s) to Drive Medical Design & Manufacturing®, one of the fastest growing major manufacturers and distributors of durable medical equipment in the home healthcare, medical/surgical and rehabilitation markets in the United States.

Our Mission is to manufacture and market world-class products which focus on innovation, functionality and value to improve the quality of life and to promote independence for the individuals that use our products.

In order for your product(s) to be properly evaluated, please review/accept the Terms & Conditions and provide answers to the following questions.

*Submission Date:  04/20/2014

Contact Information

*Name:
Company Name (if applicable):   Not Applicable
Address:
City: State: Zip:
Email:  
Phone: Fax:
Website:   Not Applicable
Annual Sales Revenues:
(on Product submitted for evaluation)
  Not Applicable

Product Category (select all that apply)

Bath Safety Crutches Power Mobility Transport / Wheelchairs
Beds Commodes Respiratory Walkers
Canes Personal Care    

What is the current stage of your product?

Idea Stage (untested) Working Model In Production
Sketches Rough Prototype

Will this item be covered by Medicare?

Yes No Don't Know
Billing Code:

Patent Status

Nothing Done Yet Patent Pending
Did a Search (provide findings, if any)   Have a Patent
        Patent Number:
Filed Provisional Application  

How would you describe your product in just a few sentences?

What is the primary problem your product solves, and/or the primary benefit it provides?

Submission Enclosures (select all that apply)

Providing Photographs, Videos, and or Drawings will assist in a prompt response.

Questionnaire (completed) Sketches / Drawings Product / Demonstration Video
Terms & Conditions (signed) Image of Product Executive Summary
(.doc, .docx, .xls, .xlsx or .pdf)

Files

Terms & Conditions

By using this invention submission form, you agree to be bound by the following terms and conditions (the "Terms of Service" or the "Agreement"). Before you may submit any invention information, you must read and accept all the terms and conditions in the Agreement. This Agreement is effective upon acceptance for new users and terms and conditions may be updated from time to time without notice to user.

You hereby acknowledge:

  1. I am the owner of the invention information and am authorized to submit to company.
  2. I acknowledge that the disclosure is being made on a NON CONFIDENTIAL basis, and that no confidentiality obligations or legal relationships whatsoever are created by this invention submission.
  3. I acknowledge that I am free to make this submission and that by doing so I am not infringing any prior obligation of confidentiality.
  4. I acknowledge that Drive Medical Design & Manufacturing® may contact me for additional information and/or samples/prototypes if applicable.
  5. I acknowledge that Drive Medical Design & Manufacturing® may already be independently working on a currently manufactured similar technology as covered by my submission, and that I will not therefore assert any intellectual property rights against company in this respect.
*Accept the Terms & Conditions
*Title (if applicable) *Name (please print) *Date


Drive Medical Design & Manufacturing® looks forward to evaluating your submission.