Providers Please fill out the provider verification form below to become a Chara regenerative medicine provider Practitioner Name Username Clinic Name Office Address(for product shipment) City State Zip Office Phone Number E-mail Address Provider Mobile Number Degree(s) Institution that granted degree Year License Number Specialty Upload a copy of your professional licenseUpload Upload a copy of your professional license UploadPractice Web Address Office Staff authorized to Change Company Info and Place Orders: Preferred Method of Communication: Only fill in if you are not human Login