1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security |
5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series A Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
1,431,467
|
$
(1)
|
I
|
See footnote
(2)
|
Series B Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
179,317
|
$
(1)
|
I
|
See footnote
(2)
|
Convertible Promissory Notes
|
Â
(3)
|
Â
(3)
|
Common Stock
|
3,257,173.46
(3)
|
$
(3)
|
I
|
See footnote
(2)
|
Warrant to Purchase Series A Preferred Stock
|
Â
(4)
|
10/31/2015(4)
|
Series A Preferred Stock
|
67,970
|
$
5.201
|
I
|
See footnote
(2)
|
Warrant to Purchase Series A Preferred Stock
|
Â
(4)
|
07/02/2016(4)
|
Series A Preferred Stock
|
33,985
|
$
5.201
|
I
|
See footnote
(2)
|
Warrant to Purchase Series A Preferred Stock
|
Â
(4)
|
09/25/2016(4)
|
Series A Preferred Stock
|
42,484
|
$
5.201
|
I
|
See footnote
(2)
|
* |
If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** |
Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) |
The shares of Series A Preferred Stock and Series B Preferred Stock have no expiration date and are convertible at any time at the election of the holder and will automatically convert into shares of common stock in connection with the Issuer's initial public offering. |
(2) |
Held of record by Essex Woodlands Health Ventures Fund VII, L.P. (the "Fund"). The Reporting Person is a manager of Essex Woodlands Health Ventures VII, L.L.C., which is the general partner of Essex Woodlands Health Ventures VII, L.P., the general partner of the Fund. The Reporting Person disclaims beneficial ownership of these securities, except to the extent of his pecuniary interest therein. |
(3) |
Principal and accrued interest will convert upon the Issuer's initial public offering into shares of Common Stock at a conversion price equal to the lesser of (i) the public offering price of the Common Stock sold in the Issuer's initial public offering, or (ii) $18.92. Amounts shown are reported in US dollars. Additional interest will accrue prior to conversion. |
(4) |
The warrants are immediately exercisable and shall terminate on the earlier of the expiration date referenced above or the occurrence of other specified corporate transactions. Includes interest accrued through the date hereof; additional interest will accrue prior to conversion. |