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 B1' Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
12,337
|
$
(3)
|
D
|
Â
|
Series C' Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
760,656
|
$
(3)
|
D
|
Â
|
Series D' Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
514,674
|
$
(3)
|
D
|
Â
|
Series E Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
328,515
|
$
(3)
|
D
|
Â
|
Series E Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
273,762
|
$
(3)
|
I
|
Directly owned by Ruth Wertheimer
(1)
(2)
|
Warrant to purchase Common Stock
|
Â
(4)
|
10/22/2022 |
Common Stock
|
111,084
|
$
0.0913
|
D
|
Â
|
Warrant to purchase Common Stock
|
Â
(4)
|
03/28/2022 |
Common Stock
|
111,084
|
$
0.0913
|
D
|
Â
|
Warrant to purchase Common Stock
|
Â
(4)
|
12/15/2024 |
Common Stock
|
81,129
|
$
9.132
|
D
|
Â
|
Warrant to purchase Common Stock
|
Â
(4)
|
12/16/2024 |
Common Stock
|
68,440
|
$
9.132
|
I
|
Directly owned by Ruth Wertheimer
(1)
(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) |
Besides the 273,762 shares of Series E Convertible Preferred Stock and warrants to purchase 68,440 shares of Common Stock held directly by Ruth Wertheimer (as reported above), she also owns (i) an indirect, 80.5% limited partnership interest in 7 Med Health Ventures LP, as well as (ii) 100% of the outstanding equity interests of the general partner of 7 Med Health Ventures LP. She may therefore be deemed to have an indirect pecuniary interest in the shares of Common Stock and Warrants to purchase Common Stock of the Issuer held by 7 Med Health Ventures LP. |
(2) |
The Reporting Person disclaims beneficial ownership of all shares except to the extent of its pecuniary interest, if any, therein. |
(3) |
The Series B1' Convertible Preferred Stock, Series C' Convertible Preferred Stock, Series D' Convertible Preferred Stock and Series E Convertible Preferred Stock is convertible into Common Stock on an 9.132-for-1 basis into the number of shares of Common Stock as shown in column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering, and has no expiration date. |
(4) |
This warrant is fully vested and exercisable. |