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 |
Warrant to Purchase Shares of Common Stock
|
(2)
|
(2)
|
Common Stock
|
13,975
(2)
|
$
(2)
|
D
|
|
Warrant to Purchase Shares of Common Stock
|
(3)
|
(3)
|
Common Stock
|
96,994
(3)
|
$
(3)
|
I
|
By Hampshire Med Tech Partners, LP
(1)
|
Warrant to Purchase Shares of Series E Convertible Preferred
|
(4)
|
(4)
|
Common Stock
|
2,204
(4)
|
$
(4)
|
D
|
|
Series D Convertible Preferred Stock
|
(5)
|
(5)
|
Common Stock
|
16,919
(5)
|
$
(5)
|
I
|
By Hampshire Asset Managements, LLC
(6)
|
Series D Convertible Preferred Stock
|
(5)
|
(5)
|
Common Stock
|
115,655
(5)
|
$
(5)
|
I
|
By KM Healthcare Holdings
(7)
|
Series D-1 Convertible Preferred Stock
|
(8)
|
(8)
|
Common Stock
|
11,821
(8)
|
$
(8)
|
I
|
By Hampshire Healthcare Partners LP
(9)
|
Series E Convertible Preferred Stock
|
(10)
|
(10)
|
Common Stock
|
14,087
(10)
|
$
(10)
|
I
|
By Hampshire Healthcare Partners LP
(9)
|
Series F Convertible Preferred Stock
|
(11)
|
(11)
|
Common Stock
|
1,250,009
(11)
|
$
(11)
|
I
|
By Hampshire Med Tech Partners, LP
(1)
|
* |
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) |
Shares held by Hampshire Med Tech Partners, LP, of which the Reporting Person is the managing member of the general partner, Hampshire Med Tech Partners GP, LLC. The Reporting Person disclaims beneficial ownership except to the extent of any pecuniary interest therein. |
(2) |
Includes of a warrant to purchase 12,027 shares of Common Stock at an exercise price of $56.70 per share of Common Stock exercisable at any time and expiring on May 9, 2016; and a warrant to purchase 1,948 shares of Common Stock at a strike price of $85.06 per share of Common Stock exercisable at any time and expiring on June 2, 2015. |
(3) |
Consists of a warrant to purchase 96,994 shares of Common Stock at a strike price of $17.53 per share of Common Stock exercisable at any time and expiring on March 4, 2018. |
(4) |
Consists of a warrant to purchase 50,000 shares of Series E convertible preferred stock which, upon completion of the Issuer's initial public offering, will be converted to a warrant to purchase 2,204 shares of the Issuer's Common Stock at an exercise price of $56.70 per share, terminating in April 2015. This conversion is reflected in column 3 in the amount of securities underlying the derivative securities. |
(5) |
Upon the closing of the Issuer's initial public offering of shares of its Common Stock, each share of Series D Convertible Preferred Stock will convert into 1.3014 shares of the Issuer's Common Stock pursuant to the terms of the Certificate of Designation for Series D Convertible Preferred Stock of the Issuer. This conversion is reflected in column 3 in the amount of securities underlying the derivative securities. |
(6) |
Shares held by Hampshire Asset Managements, LLC, of which the Reporting Person is the presdent. The Reporting Person disclaims beneficial ownership except to the extent of any pecuniary interest therein. |
(7) |
Shares held by KM Healthcare Holdings LP. The Reporting Person shares voting and dispositive power with the general partner of KM Healthcare Holdings LP. The Reporting Person disclaims beneficial ownership except to the extent of any pecuniary interest therein. |
(8) |
Upon the closing of the Issuer's initial public offering of shares of its Common Stock, each share of Series D-1 Convertible Preferred Stock will convert into 1.6834 shares of the Issuer's Common Stock pursuant to the terms of the Certificate of Designation for Series D-1 Convertible Preferred Stock of the Issuer. This conversion is reflected in column 3 in the amount of securities underlying the derivative securities. |
(9) |
Shares held by Hampshire Healthcare Partners LP, of which the Reporting Person is the managing member of the general partner, Hampshire Special Opportunities, LLC. The Reporting Person disclaims beneficial ownership except to the extent of any pecuniary interest therein. |
(10) |
Upon the closing of the Issuer's initial public offering of shares of its Common Stock, each share of Series E Convertible Preferred Stock will convert into 1.1363 shares of the Issuer's Common Stock pursuant to the terms of the Certificate of Designation for Series E Convertible Preferred Stock of the Issuer. This conversion is reflected in column 3 in the amount of securities underlying the derivative securities. |
(11) |
Upon the closing of the Issuer's initial public offering of shares of its Common Stock, each share of Series F Convertible Preferred Stock will convert into 6.44370 shares of the Issuer's Common Stock pursuant to the terms of the Certificate of Designation for Series F Convertible Preferred Stock of the Issuer. This conversion is reflected in column 3 in the amount of securities underlying the derivative securities. |