Company Engagement Form

Please complete the form below to tell us about your innovation and your current needs, so that we can determine how best to help you. A member of our team will review your response and get in touch.

    Section 1: Applicant Details

    Section 2a: Clinical Areas and Patient Benefit

    Patient outcomesEfficiency of clinical staffEfficiency of non-clinical staff or processes

    Section 2b: Innovation to Improve Patient Outcomes

    e.g prevention, cure, avoiding harm

    Section 2c: Innovation to Improve Staff Efficiency

    e.g. faster diagnosis, faster communication


    Section 2d: Innovation to Improve Non-clinical Efficiency

    e.g. improved staff morale, better patient experience, fewer missed appointments, reduced use of locum staff

    Section 2e

    BloodCancerCardiovascularCongenitalEarEyeInfectionInflammatoryInjuriesMental HealthMetabolicMusculoskeletalNeurologicalOral & GastroReproductionRespiratorySkinStrokeGenericUrology and Incontinence
    HospitalPrimary CareCommunityCare HomePatients' HomesAmbulance or ParamedicHigh StreetWorkforce education and development

    Section 3: Your Business Case

    Please give us an idea of how your innovation will be financially sustainable

    Section 4: Evidence, collaborations and funding


    East MidlandsEasternGreater ManchesterHealth Innovation NetworkImperial College Health PartnersKent, Surrey and SussexNorth East and North CumbriaInnovation Agency: AHSN for the North West CoastOxfordSouth WestUCLPartnersWessexWest MidlandsWest of EnglandYorkshire & HumberNone

    Friends and FamilyAngel investor/venture capitalResearch councilsNIHR/SBRI/NHS EnglandCharity

    Section 5a: Innovation Readiness Levels

    From the first idea to international sales is a long journey; please let us know how far you've got

    Idea onlyIntellectual Property protectedProof of concept testedWorking prototype/pathway developedSmall scale pilot completedLarger pilot/trial completedSpread beyond initial siteCommercial customersCommercial customers in more than one country

    Section 5b: Is your Innovation ready for the Market?

    There are processes you need, and processes that are helpful. From the below, let us know how far you've got.

    Not neededNeedObtainedNot sure
    Not neededNeedObtainedNot sure
    Not neededNeedObtainedNot sure
    Not neededNeedObtainedNot sure
    Not neededNeedObtainedNot sure
    Not neededNeedObtainedNot sure
    Not neededNeedObtainedNot sure
    YesNoNot neededNot sure

    Section 6: Further Information

    Research collaboration/clinical co-developmentHelp with clinical evaluationHelp with economic evaluation/building a business caseHelp with spread and adoptionSupport to obtain grant funding

    Health Innovation SurgeryWessex AHSN and CRN Technology Support ProgrammeWessex AHSN 'Work with us' webpage