CLINIC APPLICATION

Are you ready to revolutionize patient outcomes?

Together, we can elevate patient care by providing innovative, science-backed regenerative treatments that promote healing, improve quality of life, and set new standards in modern medicine.

Clinic application

Please fill out the form and someone will be in touch with you shortly.

Clinic Information

Please fill out the form and someone will be in touch with you shortly.

Account Information

Clinic Name * NPI *

Physician First Name *

Physician Last Name *

Phone Number * Email *

Business Address

Street Address *

City *

State *

Zip Code * Fax

Contact Information

This is what we will use as the primary source for communication.

First Name *

Last Name *

Email * Phone Number *

Billing Information

Please provide billing address details.

Street Address *

City *

State / Region *

Postal / Zip Code *

Referring Representative

We take your privacy seriously. By clicking "Submit", you agree to share your information with Regenerative Research Group to contact you (including through automated means; e.g. autodialing, text and pre-recorded messaging) via telephone, mobile device (including SMS and MMS) and/or email, even if your telephone number is currently listed on any state, federal or corporate Do Not Call list. Consent is not required to receive services. Regenerative Research Group will not transfer or assign your consent to receive marketing messages to a third party for them to market to you.