1A – F4 – Demographics – VERTEX SPINE

VERTEX SPINE

Demographics

First Name

Last Name

Date of Birth

Phone

Email

Home Address

Photo ID / DL (Front)

Photo ID / DL (Back)

I understand that charges for services rendered are my responsibility regardless of insurance coverage.

Do You Intend to Utilize Insurance Benefits

Yes No

Do You Have REGENEXX Coporate Benefits

Yes No

Primary Insurance

Primary Insurance Company

ID#

Group#

First Name on Card

Last Name on Card

Cardholder DOB

Insurance Card (Front)

Insurance Card (Back)

Secondary Insurance

Secondary Insurance Company

ID#

Group#

First Name on Card

Last Name on Card

Cardholder DOB

Insurance Card (Front)

Insurance Card (Back)

REGENEXX

Do You Have REGENEXX Coverage for Orthobiologics?

Yes - You must include your card No

ID#

Group#

First Name on Card

Last Name on Card

Cardholder DOB

Regenexx Card (Front)

Regenexx Card (Back)