Form

First Name*

Last Name*

Email*

Country/Region*

Company*

Company Website URL*

Company size*

Stage of Company*

Role (Select all that apply)*

CEO

Founder

Other

What clinical segment is your solution built for?*

Cardiology

Diabetes

Genetics/Genomics

Kidney/Renal disease

Mental and behavioral health

Men’s health

Neurology

Oncology

Rare diseases

Women’s health (Fertility, Menopause, Aging)

Other

What technology is your solution based on?*

AI/ML

Clinical decision support

Digital therapeutics

EMR/EHR

Lab testing

Remote patient monitoring

Software (as a medical service)

Telehealth/telemedicine/virtual care

Wearables

Other

What population is your solution built for? *

Adolescents / Children

Aging / Elderly

Family / caregivers

Homeless individuals

Intellectual / developmental disabilities services providers

LGBTQ+ individuals

Medicaid

Medicare

People with behavioral health needs

People with disabilities

People with intellectual / developmental disabilities

People with chronic conditions

People with substance use disorders

Child-bearing women

Underserved minority populations

Uninsured individuals

Veterans

What problem does your technology solve?*

Why do you want to be considered for this forum?*

What do you believe you can contribute to this network of Founders/CEOs?*

What is your channel strategy? (check all that apply)*

Consumer

Employer

Health System

Payor

Pharma

Provider

Retail

Other

How did you learn about the Digital Health Founders Forum?*

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