New Account Registration Form

Sales Representative Information

Sales Rep Name:

Sales Rep Address

Sales Rep Email:

Sales Rep Work #:

Distribution Group:

Sales Rep Mobile #:

Facility/Practice Information

Facility/Practice Name:

Telephone:

Address

Street Address

City

State

Postal code

Fax #:

Office Hours:

Practice Contact Name:

Practice Contact Email:

Practice Providers and/or Facility Information

Provider Name, Credentials, NPI#, License#:

Provider #1

Provider #2

Provider #3

Provider #4

Provider #5

Provider #6

Insurance Information

Top 3 Payers:

MCR/MCD Percentage:

Top 3 Procedures (Est):

Volume Procedures (Est):

Title/Name

Current date:

Auth Customer Signature

Clear

Credit Card Authorization Form

Credit Card Number:

Cardholder Name:

Exp Date:

CSV:

Credit Card Type (choose one):

Visa

MasterCard

American Express

Discover

Billing Address (include city and state)

Suite / Building #:

Zip:

I hereby authorize Regenerative Biologics USA to charge my credit card to collect my payments:

Full Name

Select Date:

Signature

Clear

ACH Authorization Form

• Your account will be debited automatically when your payment is due

• Complete authorization form and attach a voided check

• Send form to RegenerativeBiologicsLLC&gmail.com

Company Name (required):

Complete Address (suite/building #, city, state, zip)

Financial Institution (required):

Complete Address (suite/building #, city, state, zip)

Bank Routing #:

Bank Account #:

I hereby authorize Regenerative Biologics USA to charge my credit card to collect my payments:

First and Last Name:

YYYY-MM-DD

Place Signature

Clear

Return and Replacement Policy

PLEASE NOTE: Regenerative Biologics LLC has a NO RETURNS POLICY. All sales are final. We accept replacement requests for product that is defective or damaged in transit. Requests for replacement of defective or damaged products must be made within 10 days of receiving the product or recognizing the defect. Please email all replacement requests to RegenerativeBiologicsLLC&gmail.com. We will respond promptly and replace the damaged or defective product.

Privacy Policy | Terms of Service