EX-4.10



 Exhibit 4.10 

Form for U.S. RSU Grants 

HELIUS MEDICAL TECHNOLOGIES, INC. 

RESTRICTED STOCK UNIT GRANT NOTICE 

(2016 OMNIBUS INCENTIVE PLAN) 

Helius Medical Technologies, Inc. (the “Company”), pursuant to Article VIII of the Company’s 2016 Omnibus Incentive Plan (the
“Plan”), hereby awards to Participant Restricted Stock Units for the number of shares of the Company’s Common Stock (“RSUs” or “Restricted Stock Units”) set forth below (sometimes
referred to as the “Award”). The Award is subject to all of the terms and conditions as set forth in this notice of grant (this “Restricted Stock Unit Grant Notice”) and in the Plan and the Restricted
Stock Unit Agreement (the “Award Agreement”), both of which are attached hereto and incorporated herein in their entirety. Capitalized terms not otherwise defined herein shall have the meanings set forth in the Plan or the
Award Agreement. In the event of any conflict between the terms in the Award and the Plan, the terms of the Plan shall control. 
  

									
		 	 Participant:
	 		 	 	 	
		 	 Grant Date:
	 		 	 	 	
		 	 Vesting Commencement Date:
	 		 	 	 	
		 	 Number of Restricted Stock Units/Shares:
	 		 	 	 	

  

									
	Vesting Schedule:	 		 	The Restricted Stock Units shall vest as follows:
[                                    ] subject to
Participant’s Termination not occurring before each such date.
			
	Issuance Schedule:	 		 	Subject to any adjustment upon certain events in accordance with Section 4.2 of the Plan, one share of Common Stock will be issued for each Restricted Stock Unit that vests at the time set forth in Section 6
of the Award Agreement.

 Additional Terms/Acknowledgements: Participant acknowledges receipt of, and understands and agrees to, this Restricted
Stock Unit Grant Notice, the Award Agreement and the Plan. Participant further acknowledges that as of the Grant Date, this Restricted Stock Unit Grant Notice, the Award Agreement and the Plan set forth the entire understanding between Participant
and the Company regarding the acquisition of the Common Stock pursuant to the Award specified above and supersede all prior oral and written agreements on the terms of this Award with the exception, if applicable, of (i) any compensation
recovery policy that is adopted by the Company or is otherwise required by applicable law, and (ii) any written employment or severance arrangement that would provide for vesting acceleration of this Award upon the terms and conditions set
forth therein. 
 By accepting this Award, Participant acknowledges having received and read this Restricted Stock Unit Grant Notice, the Award Agreement
and the Plan and agrees to all of the terms and conditions set forth in these documents. Participant consents to receive Plan documents by electronic delivery and to participate in the Plan through an on-line
or electronic system established and maintained by the Company or another third party designated by the Company. 








									
	HELIUS MEDICAL TECHNOLOGIES, INC.	 		 	PARTICIPANT
				
	By:	 	 	 		 	 
		 	Signature	 		 	Signature
					
	Title:	 	 	 		 	Date:	 	 
					
	Date:	 	 	 		 		 	

 ATTACHMENTS: Restricted Stock Unit Agreement and 2016 Omnibus Incentive Plan 

  
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 ATTACHMENT I 

RESTRICTED STOCK UNIT AGREEMENT 

  
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 HELIUS MEDICAL TECHNOLOGIES, INC.

 RESTRICTED STOCK UNIT AGREEMENT 

(2016 OMNIBUS INCENTIVE PLAN) 

Pursuant to the Restricted Stock Unit Grant Notice (the “Grant Notice”) and this Restricted Stock Unit Agreement (the
“Agreement”), Helius Medical Technologies, Inc. (the “Company”) has awarded you (“Participant”) Restricted Stock Units (“Restricted Stock Units” or
“RSUs,” sometimes referred to generally as the “Award”) pursuant to Article VIII of the Company’s 2016 Omnibus Incentive Plan (the “Plan”) for the number of Restricted
Stock Units indicated in the Grant Notice. Capitalized terms not explicitly defined in this Agreement or the Grant Notice shall have the same meanings given to them in the Plan. The terms of your RSUs, in addition to those set forth in the Grant
Notice, are as follows. 
 1.    GRANT OF THE
AWARD. This Award represents the right to be issued on a future date one (1) share of Common Stock for each Restricted Stock Unit that vests on the applicable vesting date(s) (subject to any adjustment under Section 3
below) as indicated in the Grant Notice. This Award was granted in consideration of your past or expected future services to the Company or its Affiliates. 

2.    VESTING. Subject to the limitations contained herein, your RSUs will vest, if at all,
in accordance with the vesting schedule provided in the Grant Notice, provided that vesting will cease upon your Termination. Upon such Termination, the Restricted Stock Units that were not vested on the date of such Termination will be forfeited at
no cost to the Company and you will have no further right, title or interest in or to the underlying shares of Common Stock subject to the forfeited RSUs. 

3.    NUMBER OF SHARES. The number of Restricted Stock
Units/shares subject to your Award may be adjusted from time to time upon certain events as provided in Section 4.2 of the Plan. Any additional Restricted Stock Units, shares, cash or other property that becomes subject to the Award pursuant to
this Section 3, if any, shall be subject, in a manner determined by the Board, to the same forfeiture restrictions, restrictions on transferability, and time and manner of delivery as applicable to the other Restricted Stock Units and shares
covered by your Award. Notwithstanding the provisions of this Section 3, no fractional shares or rights for fractional shares of Common Stock shall be created pursuant to this Section 3. Any fraction of a share will be rounded down to the
nearest whole share. 
 4.    SECURITIES LAW
COMPLIANCE. You may not be issued any Common Stock under your Award unless the shares of Common Stock underlying the Restricted Stock Units are either (i) then registered under the Securities Act, or
(ii) the Company has determined that such issuance would be exempt from the registration requirements of the Securities Act. Your Award must also comply with other applicable laws and regulations governing the Award, and you shall not receive
such Common Stock if the Company determines that such receipt would not be in material compliance with such laws and regulations. 

5.    TRANSFER RESTRICTIONS. Prior to the time that shares of
Common Stock have been delivered to you, you may not transfer, pledge, sell or otherwise dispose of the RSUs or the 

  
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shares issuable in respect of your RSUs, except as expressly provided in this Section 5. For example, you may not use shares that may be issued in respect of your Restricted Stock Units as
security for a loan. The restrictions on transfer set forth herein will lapse upon delivery to you of shares in respect of your vested Restricted Stock Units. 

(a)    Death. Your Award is transferable by will and by the laws of descent and distribution. At your death,
vesting of your RSUs will cease and your executor or administrator of your estate shall be entitled to receive, on behalf of your estate, any Common Stock or other consideration that vested but was not issued before your death. 

(b)    Domestic Relations Orders. Upon receiving written permission from the Board or its duly authorized
designee, and provided that you and the designated transferee enter into transfer and other agreements required by the Company, you may transfer your RSUs or the shares of Common Stock issued upon vesting of your RSUs pursuant to a domestic
relations order or marital settlement agreement that contains the information required by the Company to effectuate the transfer. You are encouraged to discuss the proposed terms of any division of this Award with the Company’s Chief Financial
Officer prior to finalizing the domestic relations order or marital settlement agreement to verify that you may make such transfer, and if so, to help ensure the required information is contained within the domestic relations order or marital
settlement agreement. 
 6.    DATE OF ISSUANCE. 

(a)    The issuance of shares in respect of the Restricted Stock Units is intended to comply with Treasury
Regulations Section 1.409A-1(b)(4) and will be construed and administered in such a manner. Subject to the satisfaction of the withholding obligations set forth in this Agreement, in the event one or more
Restricted Stock Units vests, the Company shall issue to you one (1) share of Common Stock for each Restricted Stock Unit that vests on the applicable vesting date(s) (subject to any adjustment under Section 3 above). The issuance date
determined by this paragraph is referred to as the “Original Issuance Date.” 
 (b)    If
the Original Issuance Date falls on a date that is not a business day, delivery shall instead occur on the next following business day. In addition, if: 

(i)    the Original Issuance Date does not occur (1) during an “open window period” applicable to
you, as determined by the Company in accordance with the Company’s then-effective policy on trading in Company securities, or (2) on a date when you are otherwise permitted to sell shares of Common Stock on an established stock exchange or
stock market, and 
 (ii)    either (1) Withholding Taxes do not apply, or (2) the Company
decides, prior to the Original Issuance Date, (A) not to satisfy the Withholding Taxes by withholding shares of Common Stock from the shares otherwise due, on the Original Issuance Date, to you under this Award, and (B) not to permit you
to pay your Withholding Taxes in cash, 

  
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then the shares that would otherwise be issued to you on the Original Issuance Date will not be delivered on such Original Issuance Date and will instead be delivered on the first
business day when you are not prohibited from selling shares of the Company’s Common Stock in the open public market, but in no event later than December 31 of the calendar year in which the Original Issuance Date occurs (that is, the last
day of your taxable year in which the Original Issuance Date occurs), or, if and only if permitted in a manner that complies with Treasury Regulations Section 1.409A-1(b)(4), no later than the date that
is the later of (i) the 15th day of the third month following the end of the calendar year in which such shares of Common Stock under this Award are no longer subject to a “substantial risk of forfeiture” within the meaning of
Treasury Regulation Section 1.409A-1(d) or (ii) the 15th day of the third month following the end of the Company’s fiscal year in which such shares of Common Stock under this Award are no longer
subject to a “substantial risk of forfeiture” within the meaning of Treasury Regulation Section 1.409A-1(d). 

(c)    The form of delivery (e.g., a stock certificate or electronic entry evidencing such shares) shall be
determined by the Company. 
 7.    DIVIDENDS. You shall receive no benefit or
adjustment to your Award with respect to any cash dividend, stock dividend or other distribution that does not result from an event set forth in Section 4.2 of the Plan. 

8.    RESTRICTIVE LEGENDS. The shares of Common Stock issued under your Award
shall be endorsed with appropriate legends as determined by the Company. 
 9.    EXECUTION
OF DOCUMENTS. You hereby acknowledge and agree that the manner selected by the Company by which you indicate your consent to your Grant Notice is also deemed to be your execution of your Grant Notice and of this
Agreement. 
 10.    AWARD NOT A SERVICE
CONTRACT. 
 (a)    Nothing in this Agreement (including, but not limited to,
the vesting of your RSUs or the issuance of the shares subject to your RSUs), the Plan or any covenant of good faith and fair dealing that may be found implicit in this Agreement or the Plan shall: (i) confer upon you any right to continue in
the employ of, or affiliation with, the Company or an Affiliate; (ii) constitute any promise or commitment by the Company or an Affiliate regarding the fact or nature of future positions, future work assignments, future compensation or any
other term or condition of employment or affiliation; (iii) confer any right or benefit under this Agreement or the Plan unless such right or benefit has specifically accrued under the terms of this Agreement or Plan; or (iv) deprive the
Company of the right to terminate you at will and without regard to any future vesting opportunity that you may have. 

(b)    The Company has the right to reorganize, sell, spin-out or otherwise
restructure one or more of its businesses or Affiliates at any time or from time to time, as it deems appropriate (a “reorganization”). Such a reorganization could result in your Termination, or the termination of Affiliate
status of your employer and the loss of benefits available to you under this Agreement, including but not limited to, the termination of the right 

  
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to continue vesting in the Award. This Agreement, the Plan, the transactions contemplated hereunder and the vesting schedule set forth herein or any covenant of good faith and fair dealing that
may be found implicit in any of them do not constitute an express or implied promise of continued engagement as an employee or consultant for the term of this Agreement, for any period, or at all, and shall not interfere in any way with the
Company’s right to conduct a reorganization. 
 11.    WITHHOLDING
OBLIGATIONS. 
 (a)    On each vesting date, and on or before the time you receive a
distribution of the shares underlying your Restricted Stock Units, and at any other time as reasonably requested by the Company in accordance with applicable tax laws, you hereby authorize any required withholding from the Common Stock issuable to
you and/or otherwise agree to make adequate provision in cash for any sums required to satisfy the federal, state, local and foreign tax withholding obligations of the Company or any Affiliate that arise in connection with your Award (the
“Withholding Taxes”). Additionally, the Company or any Affiliate may, in its sole discretion, satisfy all or any portion of the Withholding Taxes obligation relating to your RSUs by any of the following means or by a
combination of such means: (i) withholding from any compensation otherwise payable to you by the Company; (ii) causing you to tender a cash payment; (iii) permitting or requiring you to enter into a “same day sale”
commitment, if applicable, with a broker-dealer that is a member of the Financial Industry Regulatory Authority (a “FINRA Dealer”) whereby you irrevocably elect to sell a portion of the shares to be delivered in connection
with your Restricted Stock Units to satisfy the Withholding Taxes and whereby the FINRA Dealer irrevocably commits to forward the proceeds necessary to satisfy the Withholding Taxes directly to the Company and/or its Affiliates; or
(iv) withholding shares of Common Stock from the shares of Common Stock issued or otherwise issuable to you in connection with the Award with a Fair Market Value (measured as of the date shares of Common Stock are issued to pursuant to
Section 6) equal to the amount of such Withholding Taxes; provided, however, that the number of such shares of Common Stock so withheld will not exceed the amount necessary to satisfy the Company’s required tax withholding
obligations using the minimum statutory withholding rates for federal, state, local and foreign tax purposes, including payroll taxes, that are applicable to supplemental taxable income; provided, further, that to the extent necessary
to qualify for an exemption from application of Section 16(b) of the Exchange Act, if applicable, such share withholding procedure will be subject to the express prior approval of the Compensation Committee of the Board; and provided, further,
that the Company or an Affiliate electing to satisfy all or any portion of the Withholding Taxes due with respect to any Restricted Stock Units that vest on any specific vesting date shall not obligate the Company or any Affiliate, and shall not
provide you with any right, to satisfy all or any portion of the Withholding Taxes due with respect to any Restricted Stock Units that vest on any other date. 

(b)    Unless the tax withholding obligations of the Company and/or any Affiliate are satisfied, the Company shall
have no obligation to deliver to you any Common Stock. 

  
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 (c)    In the event the Company’s obligation to withhold arises
prior to the delivery to you of Common Stock or it is determined after the delivery of Common Stock to you that the amount of the Company’s withholding obligation was greater than the amount withheld by the Company, you agree to indemnify and
hold the Company harmless from any failure by the Company to withhold the proper amount. 

12.    TAX CONSEQUENCES. The Company has no duty or obligation to minimize the
tax consequences to you of this Award and shall not be liable to you for any adverse tax consequences to you arising in connection with this Award. You are hereby advised to consult with your own personal tax, financial and/or legal advisors
regarding the tax consequences of this Award and by signing the Grant Notice, you have agreed that you have done so or knowingly and voluntarily declined to do so. You understand that you (and not the Company) shall be responsible for your own tax
liability that may arise as a result of this investment or the transactions contemplated by this Agreement. 

13.    DETRIMENTAL ACTIVITY. Your Award, the RSUs and the shares issued upon
settlement of the Award and RSUs and any associated gain shall be subject to Section 8.2(e) of the Plan regarding the effects of engaging in Detrimental Activity. 

14.    UNSECURED OBLIGATION. Your Award is unfunded, and as a holder of vested
RSUs, you shall be considered an unsecured creditor of the Company with respect to the Company’s obligation, if any, to issue shares or other property pursuant to this Agreement. You shall not have voting or any other rights as a stockholder of
the Company with respect to the shares to be issued pursuant to this Agreement until such shares are issued to you pursuant to Section 6 of this Agreement. Upon such issuance, you will obtain full voting and other rights as a stockholder of the
Company. Nothing contained in this Agreement, and no action taken pursuant to its provisions, shall create or be construed to create a trust of any kind or a fiduciary relationship between you and the Company or any other person. 

15.    NOTICES. Any notice or request required or permitted hereunder shall be given in writing to
each of the other parties hereto and shall be deemed effectively given on the earlier of (i) the date of personal delivery, including delivery by express courier, or delivery via electronic means, or (ii) the date that is five
(5) days after deposit in the United States Post Office (whether or not actually received by the addressee), by registered or certified mail with postage and fees prepaid, addressed at the following addresses, or at such other address(es) as a
party may designate by ten (10) days’ advance written notice to each of the other parties hereto: 
  

									
		 	COMPANY:	 		 	Helius Medical Technologies, Inc.
 Attn: Stock Administrator

41 University Drive, Suite 400
 Newtown, PA
18940
	 	
					
		 	PARTICIPANT:	 		 	Your address as on file with the Company
 at the time notice is given
	 	

 16.    HEADINGS. The headings of the Sections
in this Agreement are inserted for convenience only and shall not be deemed to constitute a part of this Agreement or to affect the meaning of this Agreement. 

  
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 17.    MISCELLANEOUS. 

(a)    The rights and obligations of the Company under your Award shall be transferable by the Company to any one
or more persons or entities, and all covenants and agreements hereunder shall inure to the benefit of, and be enforceable by, the Company’s successors and assigns. 

(b)    You agree upon request to execute any further documents or instruments necessary or desirable in the sole
determination of the Company to carry out the purposes or intent of your Award. 
 (c)    You acknowledge and
agree that you have reviewed your Award in its entirety, have had an opportunity to obtain the advice of counsel prior to executing and accepting your Award and fully understand all provisions of your Award. 

(d)    This Agreement shall be subject to all applicable laws, rules, and regulations, and to such approvals by any
governmental agencies or national securities exchanges as may be required. 
 (e)    All obligations of the
Company under the Plan and this Agreement shall be binding on any successor to the Company, whether the existence of such successor is the result of a direct or indirect purchase, merger, consolidation, or otherwise, of all or substantially all of
the business and/or assets of the Company. 
 18.    GOVERNING PLAN
DOCUMENT. Your Award is subject to all the provisions of the Plan, the provisions of which are hereby made a part of your Award, and is further subject to all interpretations, amendments, rules and regulations which
may from time to time be promulgated and adopted pursuant to the Plan. Your Award (and any compensation paid or shares issued under your Award) is subject to recoupment in accordance with The Dodd–Frank Wall Street Reform and Consumer
Protection Act and any implementing regulations thereunder, any clawback policy adopted by the Company and any compensation recovery policy otherwise required by applicable law. No recovery of compensation under such a clawback policy will be an
event giving rise to a right to voluntarily terminate employment upon a resignation for “good reason,” or for a “constructive termination” or any similar term under any plan or agreement with the Company. 

19.    EFFECT ON OTHER EMPLOYEE
BENEFIT PLANS. The value of the RSUs subject to this Agreement or the stock underlying the RSUs upon issuance to you shall not be included as compensation, earnings, salaries, or other similar terms used when
calculating benefits under any employee benefit plan (other than the Plan) sponsored by the Company or any Affiliate except as such plan otherwise expressly provides. The Company expressly reserves its rights to amend, modify, or terminate any or
all of the employee benefit plans of the Company or any Affiliate. 

  
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 20.    CHOICE OF
LAW. The interpretation, performance and enforcement of this Agreement shall be governed by the law of the State of Wyoming without regard to that state’s conflicts of laws rules. 

21.    SEVERABILITY. If all or any part of this Agreement or the Plan is
declared by any court or governmental authority to be unlawful or invalid, such unlawfulness or invalidity shall not invalidate any portion of this Agreement or the Plan not declared to be unlawful or invalid. Any Section of this Agreement (or part
of such a Section) so declared to be unlawful or invalid shall, if possible, be construed in a manner which will give effect to the terms of such Section or part of a Section to the fullest extent possible while remaining lawful and valid. 

22.    OTHER DOCUMENTS. You acknowledge receipt of and the
right to receive a document providing the information required by Rule 428(b)(1) promulgated under the Securities Act, which includes the Plan prospectus. In addition, you acknowledge receipt of the Company’s Insider Trading Policy. 

23.    AMENDMENT. This Agreement may not be modified, amended or terminated except by an
instrument in writing, signed by you and by a duly authorized representative of the Company. Notwithstanding the foregoing, this Agreement may be amended solely by the Board by a writing which specifically states that it is amending this Agreement,
so long as a copy of such amendment is delivered to you, and provided that, except as otherwise expressly provided in the Plan, no such amendment materially adversely affecting your rights hereunder may be made without your written consent. Without
limiting the foregoing, the Board reserves the right to change, by written notice to you, the provisions of this Agreement in any way it may deem necessary or advisable to carry out the purpose of the Award as a result of any change in applicable
laws or regulations or any future law, regulation, ruling, or judicial decision, provided that any such change shall be applicable only to rights relating to that portion of the Award which is then subject to restrictions as provided herein. 

24.    COMPLIANCE WITH SECTION 409A OF THE
CODE. This Award is intended to comply with the “short-term deferral” rule set forth in Treasury Regulation Section 1.409A-1(b)(4). Notwithstanding the
foregoing, if it is determined that the Award fails to satisfy the requirements of the short-term deferral rule and is otherwise deferred compensation subject to Section 409A, and if you are a “Specified Employee” (within the meaning set
forth in Section 409A(a)(2)(B)(i) of the Code) as of the date of your “separation from service” (within the meaning of Treasury Regulation Section 1.409A-1(h) and without regard to any alternative
definition thereunder), then the issuance of any shares that would otherwise be made upon the date of the separation from service or within the first six (6) months thereafter will not be made on the originally scheduled date(s) and will
instead be issued in a lump sum on the date that is six (6) months and one day after the date of the separation from service, with the balance of the shares issued thereafter in accordance with the original vesting and issuance schedule set
forth above, but if and only if such delay in the issuance of the shares is necessary to avoid the imposition of adverse taxation on you in respect of the shares under Section 409A of the Code. Each installment of shares that vests is intended to
constitute a “separate payment” for purposes of Treasury Regulation Section 1.409A-2(b)(2). 

  
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 * * * * * 

This Restricted Stock Unit Agreement shall be deemed to be signed by the Company and the Participant upon the signing by the Participant of
the Restricted Stock Unit Grant Notice to which it is attached. 

  
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 ATTACHMENT II 

2016 OMNIBUS INCENTIVE PLAN 

  
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