Exhibit 10.4

THIS WARRANT MAY NOT BE SOLD, TRANSFERRED OR OTHERWISE DISPOSED OF EXCEPT AS
SPECIFIED HEREIN. NEITHER THE RIGHTS REPRESENTED BY THIS WARRANT NOR THE SHARES
ISSUABLE UPON THE EXERCISE HEREOF HAVE BEEN REGISTERED FOR OFFER OR SALE UNDER
THE SECURITIES ACT OF 1933, AS AMENDED, OR APPLICABLE STATE LAW. SUCH RIGHTS AND
SHARES MAY NOT BE SOLD OR OFFERED FOR SALE IN WHOLE OR IN PART EXCEPT IN
ACCORDANCE WITH THE PROVISIONS HEREOF.

 

Warrant No.:

  Issuance Date:         , 2011

Number of Warrant Shares:

  Warrant Exercise Price: USD$.01 per share

MiMedx Group, Inc.

Form of Warrant to Purchase Common Stock

MiMedx Group, Inc., a Florida corporation (the “Company”), hereby certifies that
                , the registered holder hereof, or its permitted assigns
(“Holder”), is entitled, subject to the terms set forth below, including without
limitation Section 3 hereof, to purchase from the Company upon surrender of this
warrant (the “Warrant”), at any time or times on or after, and subject to the
occurrence of, the Effective Date hereof but not after 5:00 P.M. (Eastern
Standard Time) on the Expiration Date (as defined herein), all or any part of
the Warrant Shares (as defined herein), of fully paid and nonassessable Common
Stock (as defined herein) of the Company by payment of the applicable aggregate
Warrant Exercise Price (as defined herein) in lawful money of the United States.

1. Definitions. The following words and terms as used in this Warrant shall have
the following meanings:

(a) “2011 Gross Revenues” means the Company’s total revenue from all sources on
a consolidated basis, for the year ending December 31, 2011, as reflected in its
audited financial statements.

(b) “Assignment Form” shall have the meaning given to such term in Section 14(h)
of this Warrant.

(c) “Change in Control” means any of the following transactions: (i) a share
exchange, consolidation or merger of the Company with or into any other entity
or any other corporate reorganization whether or not the Company is the
surviving entity (unless the shareholders of the Company immediately prior to
such share exchange, consolidation, merger or reorganization hold in excess of
fifty percent (50%) of the general voting power of the Company or the surviving
entity, as the case may be, immediately after the closing of such transaction);
(ii) a transaction or series of related transactions in which in excess of fifty
percent (50%) of the Company’s general voting power is transferred to a third
party (or group of affiliated third parties) that were not previously
shareholders of the Company; or (iii) a sale of all or substantially all of the

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assets of the Company (unless the shareholders of the Company immediately prior
to such sale hold in excess of fifty percent (50%) of the general voting power
of the purchasing party or parties). The determination of “general voting power”
as used herein shall be based on the aggregate number of votes that are
attributable to outstanding securities entitled to vote in the election of
directors, general partners, managers or persons performing analogous functions
to directors of the entity in question, without regard to contractual
arrangements that establish a management structure or that vest the right to
designate directors in certain parties.

(d) “Common Stock” means (i) the Company’s common stock and (ii) any capital
stock resulting from a reclassification of such “Common Stock.”

(e) “Company” means MiMedx Group, Inc., a Florida corporation.

(f) “Convertible Securities” means any securities issued by the Company which
are convertible into or exchangeable for, directly or indirectly, shares of
Common Stock.

(g) “Effective Date” means the first to occur of the following: (i) the first
business day after the Measurement Date if and only if the Company’s 2011 Gross
Revenues are less than $11,500,000, and (ii) notice to the Holder of the
anticipated closing of a Change in Control, pursuant to Section 3, prior to the
Measurement Date.

(h) “Exercise Date” means any date after the Effective Date, prior to the
Expiration Date or other termination hereof, on which notice of exercise hereof
is given by Holder.

(i) “Expiration Date” means the date which is five (5) years after the Issuance
Date as shown on the face hereof; provided however that this Warrant may
terminate earlier as provided in Section 3 hereof.

(j) “Holder” shall have that meaning given to such term in the introductory
paragraph of this Warrant.

(k) “Market Price means the fair market value of one share of Common Stock
determined as follows: (i) where there exists a public market for the Company’s
Common Stock at the time of such exercise, the fair market value per share shall
be the closing trading price of the Common Stock quoted in the Over-The-Counter
Market Summary or the last reported sale price of the Common Stock or the
closing price quoted on the NASDAQ National Market System or on any exchange on
which the Common Stock is listed, whichever is applicable, for the five
(5) trading days (or such fewer number of trading days as the Company’s Common
Stock may have been publicly traded) ending on the trading day prior to the date
of determination of fair market value and (ii) if at any time the Common Stock
is not listed on any domestic exchange or quoted in the NASDAQ System or the
domestic over-the-counter market, the higher of (A) the book value thereof, as
determined by any firm of independent public accountants of recognized standing
selected by the Board of Directors, as at the last day as of which such
determination shall have been made, or (B) the fair value thereof determined in

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good faith by the Board of Directors as of the date which is within fifteen
(15) days of the date as of which the determination is to be made (in
determining the fair value thereof, the Board of Directors shall consider stock
market valuations and price to earnings ratios of comparable companies in
similar industries).

(l) “Measurement Date” means the date on which the Company files with the SEC
its audited financial statements for the fiscal year ending December 31, 2011.

(m) “SEC” means the Securities and Exchange Commission.

(n) “Securities Act” means the Securities Act of 1933, as amended.

(o) “Subscription Notice” shall have that meaning given to such term in
Section 2(a) of this Warrant.

(p) “Warrant” shall have that meaning given to such term in the introductory
paragraph of this document.

(q) “Warrant Exercise Price” shall initially be the amount per share shown above
on the face hereof.

(r) “Warrant Shares” means the shares of Common Stock subject to this Warrant
and shown above on the face hereof.

(s) Other Definitional Provisions.

(i) Except as otherwise specified herein, all references herein (A) to any
person other than the Company, shall be deemed to include such person’s
successors and permitted assigns, (B) to the Company shall be deemed to include
the Company’s successors and (C) to any applicable law defined or referred to
herein, shall be deemed references to such applicable law as the same may have
been or may be amended or supplemented from time to time.

(ii) When used in this Warrant, the words “herein,” “hereof,” and “hereunder,”
and words of similar import, shall refer to this Warrant as a whole and not to
any provision of this Warrant, and the words “Section,” “Schedule,” and
“Exhibit” shall refer to Sections of, and Schedules and Exhibits to, this
Warrant unless otherwise specified.

(iii) Whenever the context so requires the neuter gender includes the masculine
or feminine, and the singular number includes the plural, and vice versa.

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2. Exercise of Warrant.

(a) Subject to the terms and conditions hereof (including, without limitation,
the termination provisions set forth herein), this Warrant may be exercised in
whole or in part, at any time during normal business hours on or after the
Effective Date and prior to 5:00 p.m. (Eastern Standard Time) on the Expiration
Date. The rights represented by this Warrant may be exercised by the holder
hereof then registered on the books of the Company, in whole or from time to
time in part (except that this Warrant shall not be exercisable as to a
fractional share), by: (i) delivery of a written notice, in the form of the
subscription notice attached as Exhibit A hereto (the “Subscription Notice”), of
such holder’s election to exercise this Warrant, which notice shall specify the
number of Warrant Shares to be purchased; (ii) payment to the Company of an
amount equal to the Warrant Exercise Price multiplied by the number of Warrant
Shares as to which this Warrant is being exercised (plus any applicable issue or
transfer taxes) in cash, by wire transfer or by certified or official bank
check; and (iii) the surrender of this Warrant, properly endorsed, at the
principal office of the Company in Kennesaw, Georgia (or at such other agency or
office of the Company as the Company may designate by notice to the Holder);
provided, that if such Warrant Shares are to be issued in any name other than
that of the Holder, such issuance shall be deemed a transfer and the provisions
of Section 14 shall be applicable. In the event of any exercise of the rights
represented by this Warrant, a certificate or certificates for the Warrant
Shares so purchased, registered in the name of, or as directed by, the Holder,
shall be delivered to, or as directed by the Holder within a reasonable time
after the date on which such rights shall have been so exercised. In the event
that this Warrant becomes exercisable due to receipt by the Holder prior to the
Measurement Date of notice of an anticipated closing of a Change in Control, the
exercise of this Warrant shall be subject to, and contingent upon, the
consummation of such Change in Control.

(b) Unless the rights represented by this Warrant shall have expired or have
been fully exercised, the Company shall issue, within such fifteen (15) day
period, a new Warrant identical in all respects to this Warrant exercised except
(x) such new warrant shall represent rights to purchase the number of Warrant
Shares purchasable immediately prior to such exercise under the warrant
exercised, less the number of Warrant Shares with respect to which such original
Warrant was exercised, and (y) the Warrant Exercise Price thereof shall be,
subject to further adjustment as provided in this Warrant, the Warrant Exercise
Price of this Warrant exercised. The person in whose name any certificate for
Warrant Shares is issued upon exercise of this Warrant shall for all purposes be
deemed to have become the holder of record of such Warrant Shares immediately
prior to the close of business on the date on which this Warrant was surrendered
and payment of the amount due in respect of such exercise and any applicable
taxes was made, irrespective of the date of delivery of such share certificate,
except that, if the date of such surrender and payment is a date when the stock
transfer books of the Company are properly closed, such person shall be deemed
to have become the holder of such Warrant Shares at the opening of business on
the next succeeding date on which the stock transfer books are open.

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3. Termination of Warrant. This Warrant shall automatically terminate without
exercise and shall be null and void (i) on the Measurement Date, if the 2011
Gross Revenues of the Company equals or exceeds $11,500,000, and
(ii) immediately prior to the consummation of a Change in Control. The Company
shall give the Holder notice of an anticipated closing date of such Change in
Control at the same time as notification thereof is provided to the shareholders
of the Company generally and the Holder shall be entitled to exercise this
Warrant, subject to the last sentence of Section 2(a), at any time after such
notice and prior to such closing.

4. Covenants as to Common Stock.

(a) The Company covenants and agrees that all Warrant Shares that may be issued
upon the exercise of the rights represented by this Warrant will, upon issuance,
be validly issued, fully paid and nonassessable. The Company further covenants
and agrees that during the period within which the rights represented by this
Warrant may be exercised, the Company will at all times have authorized and
reserved a sufficient number of shares of Common Stock to provide for the
exercise of the rights then represented by this Warrant and that the par value
of said shares will at all times be less than or equal to the applicable Warrant
Exercise Price.

(b) If any shares of Common Stock reserved or to be reserved to provide for the
exercise of the rights then represented by this Warrant require registration
with or approval of any governmental authority under any federal or state law
before such shares may be validly issued to the Holder, then the Company
covenants that it will in good faith and as expeditiously as possible endeavor
to secure such registration or approval, as the case may be.

5. Adjustment of Warrant Exercise Price upon Stock Splits, Dividends,
Distributions and Combinations; and Adjustment of Number of Shares.

(a) In case the Company shall at any time split or subdivide its outstanding
shares of Common Stock into a greater number of shares or issue a stock dividend
(including any distribution of stock without consideration) or make a
distribution with respect to outstanding shares of Common Stock or Convertible
Securities payable in Common Stock or in Convertible Securities, the Warrant
Exercise Price in effect immediately prior to such subdivision or stock dividend
or distribution shall be proportionately reduced and conversely, in case the
outstanding shares of Common Stock of the Company shall be combined into a
smaller number of shares, the Warrant Exercise Price in effect immediately prior
to such combination shall be proportionately increased, in each case, by
multiplying the then effective Warrant Exercise Price by a fraction, the
numerator of which shall be the total number of shares of Common Stock
outstanding immediately prior to such subdivision, stock dividend, distribution
or combination (determined on a fully diluted basis), and the denominator of
which shall be the total number of shares of Common Stock, immediately after
such subdivision, stock dividend, distribution or combination (determined on a
fully diluted basis), and the product so obtained shall thereafter be the
Warrant Exercise Price. For purposes of this Warrant, “on a fully diluted basis”
means that all issued and outstanding capital stock of the Company, including
all Convertible Securities, and all outstanding options and warrants, whether or
not vested, shall be taken into account.

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(b) Upon each adjustment of the Warrant Exercise Price as provided above in this
Section 5, the Holder shall thereafter be entitled to purchase, at the Warrant
Exercise Price resulting from such adjustment, the number of shares (calculated
to the nearest tenth of a share) obtained by multiplying the Warrant Exercise
Price in effect immediately prior to such adjustment by the number of shares
purchasable pursuant hereto immediately prior to such adjustment and dividing
the product thereof by the Warrant Exercise Price immediately after such
adjustment.

6. Reorganization, Reclassification, Etc. Subject to the provisions of Section 3
hereof, in case of any capital reorganization, or of any reclassification of the
capital stock of the Company (other than a change in par value or from par value
to no par value or from no par value to par value or as a result of a split-up
or combination), this Warrant shall, after such capital reorganization or
reclassification of capital stock, entitle the Holder hereof to purchase the
kind and number of shares of stock or other securities or property of the
Company or of the corporation resulting from such reorganization or
consolidation, as the case may be, to which the holder hereof would have been
entitled if he had held the Common Stock issuable upon the exercise hereof
immediately prior to such capital reorganization or reclassification of capital
stock, and, in any such case, appropriate provision shall be made with respect
to the rights and interests of the holder of this Warrant to the end that the
provisions thereof (including without limitation provisions for adjustment of
the Warrant Exercise Price and of the number of shares purchasable upon the
exercise of this Warrant) shall thereafter be applicable, as nearly as may be
practicable in relation to any shares of stock, securities, or assets thereafter
deliverable upon the exercise of the rights represented hereby.

7. Notice of Adjustment of Warrant Exercise Price. Upon any adjustment of the
Warrant Exercise Price, then the Company shall give notice thereof to the Holder
of this Warrant, which notice shall state the Warrant Exercise Price in effect
after such adjustment and the increase, or decrease, if any, in the number of
Warrant Shares purchasable at the Warrant Exercise Price upon the exercise of
this Warrant, setting forth in reasonable detail the method of calculation and
the facts upon which such calculation is based.

8. Computation of Adjustments. Upon each computation of an adjustment in the
Warrant Exercise Price and the number of shares which may be subscribed for and
purchased upon exercise of this Warrant, the Warrant Exercise Price shall be
computed to the nearest cent (i.e. fraction of .5 of a cent, or greater, shall
be rounded to the next highest cent) and the number of shares which may be
subscribed for and purchased upon exercise of this Warrant shall be calculated
to the nearest whole share (i.e. fractions of less than one half of a share
shall be disregarded and fractions of one half of a share, or greater, shall be
treated as being a whole share). No such adjustment shall be made however, if
the change in the Warrant Exercise Price would be less than $.001 per share, but
any such lesser adjustment shall be made (i) at the time and together with the
next subsequent adjustment which, together with any adjustments carried forward,
shall amount to $.001 per share or more, or (ii) if earlier, upon the third
anniversary of the event for which such adjustment is required.

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9. Net Issue Exercise. Notwithstanding any provisions herein to the contrary, if
the Market Price of one share of Common Stock is greater than the Warrant
Exercise Price at the date of exercise of this Warrant, in lieu of exercising
this Warrant by payment of cash, the Holder may elect to receive shares equal to
the value (as determined below) of this Warrant (or portion thereof being
canceled) by surrender of this Warrant at the principal office of the Company
together with the duly executed Notice of Exercise, in which event the Company
shall issue to the Holder a number of shares of the Common Stock computed using
the following formula:

X = Y(A-B)

A

WHERE X = the number of shares of Common Stock to be issued to the Holder;

Y = the number of shares of the Common Stock purchasable under this Warrant or,
if only a portion of this Warrant is being exercised, the number of shares
underlying this Warrant to the extent exercised (at the date of such exercise);

A = the Market Price of one share of Common Stock (at the date of such
calculation); and

B = Warrant Exercise Price (at the date of such calculation).

10. No Change in Warrant Terms on Adjustment. Irrespective of any adjustment in
the Warrant Exercise Price or the number of shares of Common Stock issuable upon
exercise hereof, this Warrant, whether theretofore or thereafter issued or
reissued, may continue to express the same price and number of shares as are
stated herein and the Warrant Exercise Price and such number of shares specified
herein shall be deemed to have been so adjusted.

11. Taxes. The Company shall not be required to pay any tax or taxes
attributable to the initial issuance of the Warrant Shares or any transfer
involved in the issue or delivery of any certificates for Warrant Shares in a
name other than that of the registered holder hereof or upon any transfer of
this Warrant.

12. Warrant Holder Not Deemed a Shareholder. No holder, as such, of this Warrant
shall be entitled to vote or receive dividends or be deemed the holder of shares
of the Company for any purpose, nor shall anything contained in this Warrant be
construed to confer upon the holder hereof, as such, any of the rights of a
shareholder of the Company or any right to vote, give or withhold consent to any
corporate action (whether any reorganization, issue of stock, reclassification
of stock, consolidation, merger, conveyance or otherwise), receive notice of
meetings, receive dividends or subscription rights, or otherwise, prior to the
issuance of record to the holder of this Warrant of the Warrant Shares which he
is then entitled to receive upon the due exercise of this Warrant.

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13. No Limitation on Corporate Action. No provisions of this Warrant and no
right or option granted or conferred hereunder shall in any way limit, affect or
abridge the exercise by the Company of any of its corporate rights or powers to
recapitalize, amend its Articles of Incorporation, reorganize, consolidate or
merge with or into another corporation, or to transfer all or any part of its
property or assets, or the exercise of any other of its corporate rights and
powers.

14. Transfer; Opinions of Counsel; Restrictive Legends. To the extent
applicable, each certificate or other document evidencing any of the Warrant
Shares shall be endorsed with the legends set forth below, and Holder covenants
that, except to the extent such restrictions are waived by the Company, Holder
shall not transfer the Warrant Shares without complying with the restrictions on
transfer described in the legends endorsed thereon;

(a) The following legend under the Securities Act:

“THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN REGISTERED UNDER THE UNITED
STATES SECURITIES ACT OF 1933, AS AMENDED, AND MAY NOT BE SOLD, TRANSFERRED,
ASSIGNED, PLEDGED, OR HYPOTHECATED ABSENT AN EFFECTIVE REGISTRATION THEREOF
UNDER SUCH ACT UNLESS THE COMPANY HAS RECEIVED AN OPINION OF COUNSEL, REASONABLY
SATISFACTORY TO THE COMPANY AND ITS COUNSEL, THAT SUCH REGISTRATION IS NOT
REQUIRED.”

(b) If required by the authorities of any state in connection with the issuance
or sale of the Warrant Shares, the legend required by such state authority.

(c) The Company shall not be required (i) to transfer on its books either this
Warrant or any Warrant Shares which shall have been transferred in violation of
any of the provisions set forth in this Section 14, or (ii) to treat as owner of
such Warrant Shares or to accord the right to vote as such owner or to pay
dividends to any transferee to whom such Warrant Shares shall have been so
transferred.

(d) Any legend endorsed on a certificate pursuant to subsection (a) or (b) of
this Section 14 shall be removed (i) if the Warrant Shares represented by such
certificate shall have been effectively registered under the Securities Act or
otherwise lawfully sold in a public transaction, or (ii) if the holder of such
Warrant Shares shall have provided the Company with an opinion from counsel, in
form and substance reasonably acceptable to the Company and from attorneys
reasonably acceptable to the Company, stating that a public sale, transfer or
assignment of this Warrant or the Warrant Shares may be made without
registration.

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(e) Any legend endorsed on a certificate pursuant to subsection (b) of this
Section 14 shall be removed if the Company receives an order of the appropriate
state authority authorizing such removal or if the holder of this Warrant or the
Warrant Shares provides the Company with an opinion of counsel, in form and
substance reasonably acceptable to the Company and from attorneys reasonably
acceptable to the Company, stating that such state legend may be removed.

(f) Without in any way limiting the representations set forth above, Holder
further agrees not to make any disposition of all or any portion of this Warrant
at any time other than to an affiliate of the Holder; provided, however, that
such affiliate transferee agrees in writing to be subject to the terms of this
Section 14. In addition, the Holder agrees not to make any disposition of all or
any portion of the Warrant Shares unless:

(i) There is then in effect a registration statement under the Securities Act
covering such proposed disposition and such disposition is made in accordance
with such registration statement; or

(ii) Holder shall have notified the Company of the proposed disposition and
shall have furnished the Company with a detailed statement of the circumstances
surrounding the proposed disposition, and, if requested by the Company,
(A) Holder shall have furnished the Company with an opinion of counsel,
reasonably satisfactory to the Company, that such disposition will not require
registration of this Warrant or any Warrant Shares under the Securities Act and
(B) the transferee shall have furnished to the Company its agreement to abide by
the restrictions on transfer set forth herein as if it were a purchaser
hereunder.

(g) Notwithstanding the other provisions of this Section 14, no such
registration statement or opinion of counsel shall be required for any transfer
by a Holder, (i) if it is a partnership or a corporation, to a partner or pro
rata to its equity holder(s) of such Holder (or a third party duly authorized to
act on behalf of such Holder or its partners or equity holders), or (ii) if he
or she is an individual, to members of such individual’s family for estate
planning purposes; provided, however, that the transferee agrees in writing to
be subject to the terms of this Section 14.

(h) Upon delivery of the foregoing opinion of counsel (with respect to a
transfer of the Warrant Shares) and the surrender of this Warrant to the Company
at its principal office, together with (i) the assignment form annexed hereto as
Exhibit B (the “Assignment Form”) duly executed and (ii) funds sufficient to pay
any transfer tax, the Company shall, if it determines such transfer is permitted
by the terms of this Warrant, without additional charge, execute and deliver a
new Warrant in the name of the assignee named in such instrument of assignment
and this Warrant shall promptly be cancelled.

15. Lost, Stolen, Mutilated or Destroyed Warrant. If this Warrant is lost,
stolen, mutilated or destroyed, the Company shall, on such terms as to indemnity
or otherwise as it may in its discretion impose (except in the event of loss,
theft, mutilation or destruction while this Warrant is in possession of the
Company’s Escrow Agent, in which events the Company shall be solely responsible)
(which shall, in the case of a mutilated Warrant, include the surrender
thereof), issue a new Warrant of like denomination and tenor as this Warrant so
lost, stolen, mutilated or destroyed. Any such new Warrant shall constitute an
original contractual obligation of the Company, whether or not the allegedly
lost, stolen, mutilated or destroyed Warrant shall be at any time enforceable by
anyone.

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16. Representation of Holder. The Holder, by the acceptance hereof, represents
that it is acquiring this Warrant, and the Warrant Shares, for its own account,
for investment purposes, and not with a present view either to sell, distribute,
or transfer, or to offer for sale, distribution, or transfer, any of this
Warrant or the Warrant Shares, or any other securities issuable upon the
exercise thereof.

17. Restricted Securities. The Holder understands that this Warrant and the
Warrant Shares issuable upon exercise of this Warrant, will not be registered at
the time of their issuance under the Securities Act for the reason that the sale
provided for in this Warrant is exempt pursuant to Section 4(2) of the
Securities Act based on the representations of the Holder set forth herein. The
Warrant Holder represents that it is experienced in evaluating companies such as
the Company, has such knowledge and experience in financial and business matters
as to be capable of evaluating the merits and risks of its investment and has
the ability to suffer the total loss of the investment. The Holder further
represents that it has had the opportunity to ask questions of and receive
answers from the Company concerning the terms and conditions of this Warrant,
the business of the Company, and to obtain additional information to such
Holder’s satisfaction. The Holder represents that it is an “Accredited Investor”
within the meaning of Rule 501 of Regulation D under the Securities Act, as
presently in effect.

18. Notices. All Notices, requests and other communications that the Holder or
the Company is required or elects to give hereunder shall be in writing and
shall be deemed to have been given (a) upon personal delivery thereof, including
by appropriate courier service, five (5) days after delivery to the courier or,
if earlier, upon delivery against a signed receipt therefore or (b) upon
transmission by facsimile or telecopier, which transmission is confirmed, in
either case addressed to the party to be notified at the address set forth below
or at such other address as such party shall have notified the other parties
hereto, by notice given in conformity with this Section 18.

If to the Company:

MiMedx Group, Inc.

60 Chastain Center Blvd., Suite 60

Kennesaw, GA 30144

Attention: General Counsel

Facsimile: (678) 802-2860

If to the Holder:

 

 

 

 

 

 

Facsimile:                                 

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19. Miscellaneous. This Warrant and any term hereof may be changed, waived,
discharged, or terminated only by an instrument in writing signed by the party
or holder hereof against which enforcement of such change, waiver, discharge or
termination is sought. The headings in this Warrant are for purposes of
reference only and shall not limit or otherwise affect the meaning hereof.

20. Date. The Issuance Date of this Warrant is the date shown on the first page
above on the face hereof. This Warrant, in all events, shall be wholly void and
of no effect after 5:00 p.m. (Eastern Time) on the Expiration Date, except that
notwithstanding any other provisions hereof, the provisions of Section 14 shall
continue in full force and effect after such date as to any Warrant Shares or
other securities issued upon the exercise of this Warrant.

21. Severability. If any provision of this Warrant is held by a court of
competent jurisdiction to be invalid, void or unenforceable, the remaining
provisions shall nevertheless continue in full force and effect without being
impaired or invalidated in any way and shall be construed in accordance with the
purposes and tenor and effect of this Warrant.

22. Governing Law. This Warrant shall be governed by and construed and enforced
in accordance with the laws of the State of Georgia, without reference to its
conflicts of law principles.

[Signatures Contained on the Following Page]

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IN WITNESS WHEREOF, the Company has executed this Warrant as of the Issuance
Date.

 

MiMedx Group, Inc.

By:

   

Name:

 

Michael J. Senken

Title:

 

Chief Financial Officer

Acknowledged and Agreed:

HOLDER:             

 

 

Name:

Title (if applicable):

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EXHIBIT A TO

WARRANT

 

SUBSCRIPTION NOTICE

TO BE EXECUTED BY THE REGISTERED HOLDER IF SUCH REGISTERED HOLDER

DESIRES TO EXERCISE THIS WARRANT

The undersigned hereby exercises the right to purchase Warrant Shares covered by
this Warrant according to the conditions thereof and herewith [makes payment of
$                    , the aggregate Warrant Exercise Price of such Warrant
Shares in full] [tenders solely this Warrant, or applicable portion hereof, in
full satisfaction of the Warrant Exercise Price upon the terms and conditions
set forth herein.]

INSTRUCTIONS FOR REGISTRATION OF STOCK

Name                                          
                                         
                                         
                                         
                                        

(Please typewrite or print in block letters)

Address                                          
                                         
                                         
                                                                          

 

Holder Name:

By:     Name:  

Title:

 

[Net] Number of Warrant Shares Being

Purchased                                     

Dated:                                     , 20                 

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EXHIBIT B TO

WARRANT

ASSIGNMENT FORM

FOR VALUE RECEIVED,                                          
                                        hereby sells, assigns and transfers unto

Name                                          
                                         
                                         
                                         
                                        

(Please typewrite or print in block letters)

Address                                          
                                         
                                         
                                                                      

the right to purchase Common Stock represented by this Warrant to the extent of
shares as to which such right is exercisable and does hereby irrevocably
constitute and appoint Attorney, to transfer the same on the books of the
Company with full power of substitution in the premises.

Date                                          , 20             

Signature