<SEC-DOCUMENT>0001527096-21-000008.txt : 20210625
<SEC-HEADER>0001527096-21-000008.hdr.sgml : 20210625
<ACCEPTANCE-DATETIME>20210625215539
ACCESSION NUMBER:		0001527096-21-000008
CONFORMED SUBMISSION TYPE:	4
PUBLIC DOCUMENT COUNT:		2
CONFORMED PERIOD OF REPORT:	20210623
FILED AS OF DATE:		20210625
DATE AS OF CHANGE:		20210625

REPORTING-OWNER:	

	OWNER DATA:	
		COMPANY CONFORMED NAME:			DAVITA INC.
		CENTRAL INDEX KEY:			0000927066
		STANDARD INDUSTRIAL CLASSIFICATION:	SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090]
		STATE OF INCORPORATION:			DE
		FISCAL YEAR END:			1231

	FILING VALUES:
		FORM TYPE:		4
		SEC ACT:		1934 Act
		SEC FILE NUMBER:	001-40518
		FILM NUMBER:		211049755

	BUSINESS ADDRESS:	
		STREET 1:		2000 16TH STREET
		CITY:			DENVER
		STATE:			CO
		ZIP:			80202
		BUSINESS PHONE:		310-536-2668

	MAIL ADDRESS:	
		STREET 1:		2000 16TH STREET
		CITY:			DENVER
		STATE:			CO
		ZIP:			80202

	FORMER NAME:	
		FORMER CONFORMED NAME:	DAVITA HEALTHCARE PARTNERS INC.
		DATE OF NAME CHANGE:	20121107

	FORMER NAME:	
		FORMER CONFORMED NAME:	DAVITA INC
		DATE OF NAME CHANGE:	20001005

	FORMER NAME:	
		FORMER CONFORMED NAME:	TOTAL RENAL CARE HOLDINGS INC
		DATE OF NAME CHANGE:	19950524

REPORTING-OWNER:	

	OWNER DATA:	
		COMPANY CONFORMED NAME:			Cheshire MD Holdings, LLC
		CENTRAL INDEX KEY:			0001869023
		STATE OF INCORPORATION:			DE
		FISCAL YEAR END:			1231

	FILING VALUES:
		FORM TYPE:		4
		SEC ACT:		1934 Act
		SEC FILE NUMBER:	001-40518
		FILM NUMBER:		211049756

	BUSINESS ADDRESS:	
		STREET 1:		601 HAWAII STREET
		STREET 2:		ATTN JLD SECGOVFIN
		CITY:			EL SEGUNDO
		STATE:			CA
		ZIP:			90245
		BUSINESS PHONE:		3105362400

	MAIL ADDRESS:	
		STREET 1:		2000 16TH STREET
		STREET 2:		ATTN JLD SECGOVFIN
		CITY:			DENVER
		STATE:			CO
		ZIP:			80202

ISSUER:		

	COMPANY DATA:	
		COMPANY CONFORMED NAME:			Miromatrix Medical Inc.
		CENTRAL INDEX KEY:			0001527096
		STANDARD INDUSTRIAL CLASSIFICATION:	BIOLOGICAL PRODUCTS (NO DIAGNOSTIC SUBSTANCES) [2836]
		IRS NUMBER:				271285782
		STATE OF INCORPORATION:			DE
		FISCAL YEAR END:			1211

	BUSINESS ADDRESS:	
		STREET 1:		10399 WEST 70TH STREET
		CITY:			EDEN PRAIRIE
		STATE:			MN
		ZIP:			55344
		BUSINESS PHONE:		(612)202-7026

	MAIL ADDRESS:	
		STREET 1:		10399 WEST 70TH STREET
		CITY:			EDEN PRAIRIE
		STATE:			MN
		ZIP:			55344
</SEC-HEADER>
<DOCUMENT>
<TYPE>4
<SEQUENCE>1
<FILENAME>wf-form4_162467251435139.xml
<DESCRIPTION>FORM 4
<TEXT>
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<ownershipDocument>

    <schemaVersion>X0306</schemaVersion>

    <documentType>4</documentType>

    <periodOfReport>2021-06-23</periodOfReport>

    <notSubjectToSection16>0</notSubjectToSection16>

    <issuer>
        <issuerCik>0001527096</issuerCik>
        <issuerName>Miromatrix Medical Inc.</issuerName>
        <issuerTradingSymbol>MIRO</issuerTradingSymbol>
    </issuer>

    <reportingOwner>
        <reportingOwnerId>
            <rptOwnerCik>0001869023</rptOwnerCik>
            <rptOwnerName>Cheshire MD Holdings, LLC</rptOwnerName>
        </reportingOwnerId>
        <reportingOwnerAddress>
            <rptOwnerStreet1>C/O DAVITA INC.</rptOwnerStreet1>
            <rptOwnerStreet2>2000 16TH STREET</rptOwnerStreet2>
            <rptOwnerCity>DENVER</rptOwnerCity>
            <rptOwnerState>CO</rptOwnerState>
            <rptOwnerZipCode>80202</rptOwnerZipCode>
            <rptOwnerStateDescription></rptOwnerStateDescription>
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            <isDirector>0</isDirector>
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            <otherText></otherText>
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    <reportingOwner>
        <reportingOwnerId>
            <rptOwnerCik>0000927066</rptOwnerCik>
            <rptOwnerName>DAVITA INC.</rptOwnerName>
        </reportingOwnerId>
        <reportingOwnerAddress>
            <rptOwnerStreet1>2000 16TH STREET</rptOwnerStreet1>
            <rptOwnerStreet2></rptOwnerStreet2>
            <rptOwnerCity>DENVER</rptOwnerCity>
            <rptOwnerState>CO</rptOwnerState>
            <rptOwnerZipCode>80202</rptOwnerZipCode>
            <rptOwnerStateDescription></rptOwnerStateDescription>
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        <reportingOwnerRelationship>
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            <isOther>0</isOther>
            <officerTitle></officerTitle>
            <otherText></otherText>
        </reportingOwnerRelationship>
    </reportingOwner>

    <nonDerivativeTable></nonDerivativeTable>

    <derivativeTable>
        <derivativeTransaction>
            <securityTitle>
                <value>Warrants</value>
            </securityTitle>
            <conversionOrExercisePrice>
                <value>7.5</value>
            </conversionOrExercisePrice>
            <transactionDate>
                <value>2021-06-23</value>
            </transactionDate>
            <transactionCoding>
                <transactionFormType>4</transactionFormType>
                <transactionCode>X</transactionCode>
                <equitySwapInvolved>0</equitySwapInvolved>
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            <transactionAmounts>
                <transactionShares>
                    <value>240000</value>
                </transactionShares>
                <transactionPricePerShare>
                    <value>0</value>
                </transactionPricePerShare>
                <transactionAcquiredDisposedCode>
                    <value>D</value>
                </transactionAcquiredDisposedCode>
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            <exerciseDate>
                <value>2020-03-06</value>
            </exerciseDate>
            <expirationDate>
                <value>2021-06-28</value>
            </expirationDate>
            <underlyingSecurity>
                <underlyingSecurityTitle>
                    <value>Series C Preferred Stock</value>
                </underlyingSecurityTitle>
                <underlyingSecurityShares>
                    <value>240000.0</value>
                </underlyingSecurityShares>
            </underlyingSecurity>
            <postTransactionAmounts>
                <sharesOwnedFollowingTransaction>
                    <value>0</value>
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            <ownershipNature>
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                    <value>D</value>
                    <footnoteId id="F1"/>
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        </derivativeTransaction>
        <derivativeTransaction>
            <securityTitle>
                <value>Series C Preferred Stock</value>
            </securityTitle>
            <conversionOrExercisePrice>
                <footnoteId id="F2"/>
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            <transactionDate>
                <value>2021-06-23</value>
            </transactionDate>
            <transactionCoding>
                <transactionFormType>4</transactionFormType>
                <transactionCode>X</transactionCode>
                <equitySwapInvolved>0</equitySwapInvolved>
            </transactionCoding>
            <transactionAmounts>
                <transactionShares>
                    <value>240000</value>
                </transactionShares>
                <transactionPricePerShare>
                    <value>0</value>
                </transactionPricePerShare>
                <transactionAcquiredDisposedCode>
                    <value>A</value>
                </transactionAcquiredDisposedCode>
            </transactionAmounts>
            <exerciseDate>
                <footnoteId id="F2"/>
            </exerciseDate>
            <expirationDate>
                <footnoteId id="F2"/>
            </expirationDate>
            <underlyingSecurity>
                <underlyingSecurityTitle>
                    <value>Common Stock</value>
                </underlyingSecurityTitle>
                <underlyingSecurityShares>
                    <value>250000.0</value>
                </underlyingSecurityShares>
            </underlyingSecurity>
            <postTransactionAmounts>
                <sharesOwnedFollowingTransaction>
                    <value>240000</value>
                </sharesOwnedFollowingTransaction>
            </postTransactionAmounts>
            <ownershipNature>
                <directOrIndirectOwnership>
                    <value>D</value>
                    <footnoteId id="F1"/>
                </directOrIndirectOwnership>
            </ownershipNature>
        </derivativeTransaction>
        <derivativeTransaction>
            <securityTitle>
                <value>Series C Preferred Stock</value>
            </securityTitle>
            <conversionOrExercisePrice>
                <footnoteId id="F2"/>
            </conversionOrExercisePrice>
            <transactionDate>
                <value>2021-06-23</value>
            </transactionDate>
            <transactionCoding>
                <transactionFormType>4</transactionFormType>
                <transactionCode>S</transactionCode>
                <equitySwapInvolved>0</equitySwapInvolved>
                <footnoteId id="F3"/>
            </transactionCoding>
            <transactionAmounts>
                <transactionShares>
                    <value>192000</value>
                </transactionShares>
                <transactionPricePerShare>
                    <footnoteId id="F3"/>
                </transactionPricePerShare>
                <transactionAcquiredDisposedCode>
                    <value>D</value>
                </transactionAcquiredDisposedCode>
            </transactionAmounts>
            <exerciseDate>
                <footnoteId id="F2"/>
            </exerciseDate>
            <expirationDate>
                <footnoteId id="F2"/>
            </expirationDate>
            <underlyingSecurity>
                <underlyingSecurityTitle>
                    <value>Common Stock</value>
                </underlyingSecurityTitle>
                <underlyingSecurityShares>
                    <value>200000.0</value>
                </underlyingSecurityShares>
            </underlyingSecurity>
            <postTransactionAmounts>
                <sharesOwnedFollowingTransaction>
                    <value>48000</value>
                </sharesOwnedFollowingTransaction>
            </postTransactionAmounts>
            <ownershipNature>
                <directOrIndirectOwnership>
                    <value>D</value>
                    <footnoteId id="F1"/>
                </directOrIndirectOwnership>
            </ownershipNature>
        </derivativeTransaction>
        <derivativeTransaction>
            <securityTitle>
                <value>Convertible Promissory Note</value>
            </securityTitle>
            <conversionOrExercisePrice>
                <value>7.5</value>
            </conversionOrExercisePrice>
            <transactionDate>
                <value>2021-06-23</value>
            </transactionDate>
            <transactionCoding>
                <transactionFormType>4</transactionFormType>
                <transactionCode>X</transactionCode>
                <equitySwapInvolved>0</equitySwapInvolved>
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            <transactionAmounts>
                <transactionTotalValue>
                    <value>7176652.50</value>
                </transactionTotalValue>
                <transactionPricePerShare>
                    <value>0</value>
                </transactionPricePerShare>
                <transactionAcquiredDisposedCode>
                    <value>D</value>
                </transactionAcquiredDisposedCode>
            </transactionAmounts>
            <exerciseDate>
                <value>2020-03-06</value>
            </exerciseDate>
            <expirationDate>
                <value>2021-09-06</value>
            </expirationDate>
            <underlyingSecurity>
                <underlyingSecurityTitle>
                    <value>Series C Preferred Stock</value>
                </underlyingSecurityTitle>
                <underlyingSecurityShares>
                    <value>956887.0</value>
                </underlyingSecurityShares>
            </underlyingSecurity>
            <postTransactionAmounts>
                <sharesOwnedFollowingTransaction>
                    <value>0</value>
                </sharesOwnedFollowingTransaction>
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            <ownershipNature>
                <directOrIndirectOwnership>
                    <value>D</value>
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        <derivativeTransaction>
            <securityTitle>
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            <conversionOrExercisePrice>
                <footnoteId id="F2"/>
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            <transactionDate>
                <value>2021-06-23</value>
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            <transactionCoding>
                <transactionFormType>4</transactionFormType>
                <transactionCode>X</transactionCode>
                <equitySwapInvolved>0</equitySwapInvolved>
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            <transactionAmounts>
                <transactionShares>
                    <value>956887</value>
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                <transactionPricePerShare>
                    <value>0</value>
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                <transactionAcquiredDisposedCode>
                    <value>A</value>
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            <exerciseDate>
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            <expirationDate>
                <footnoteId id="F2"/>
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            <underlyingSecurity>
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                    <value>Common Stock</value>
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                <underlyingSecurityShares>
                    <value>996757.0</value>
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            <postTransactionAmounts>
                <sharesOwnedFollowingTransaction>
                    <value>1004887</value>
                </sharesOwnedFollowingTransaction>
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            <ownershipNature>
                <directOrIndirectOwnership>
                    <value>D</value>
                    <footnoteId id="F1"/>
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        </derivativeTransaction>
    </derivativeTable>

    <footnotes>
        <footnote id="F1">As a result of DaVita Inc.'s ownership interest in Cheshire MD Holdings, LLC, DaVita Inc. may be deemed to have an indirect pecuniary interest in the shares held directly by Cheshire MD Holdings, LLC.</footnote>
        <footnote id="F2">Each share of Series C Preferred Stock has no expiration date and will automatically convert into shares of Common Stock upon the closing of the Issuer's Initial Public Offering at a rate determined by dividing $7.50 by $7.20.</footnote>
        <footnote id="F3">On June 23, 2021, Cheshire MD Holdings, LLC exercised the warrant to purchase 240,000 shares of the Issuer's Series C Preferred Stock for $7.50 a share. Pursuant to the terms of the warrant, Cheshire MD Holdings, LLC paid the exercise price on a cashless basis, resulting in the Issuer withholding 192,000 of the warrant shares to pay the exercise price and issuing to Cheshire MD Holdings, LLC the remaining 48,000 shares.</footnote>
    </footnotes>

    <remarks>Exhibit 24 - Power of Attorney</remarks>

    <ownerSignature>
        <signatureName>By: Cheshire MD Holdings, LLC
Name: Steve Phillips
Title: Vice President
/s/ Stephanie Berberich, Attorney-in-Fact</signatureName>
        <signatureDate>2021-06-25</signatureDate>
    </ownerSignature>

    <ownerSignature>
        <signatureName>By: DaVita Inc.
Name: Stephanie Berberich
Title: Assistant Corporate Secretary
/s/ Stephanie Berberich</signatureName>
        <signatureDate>2021-06-25</signatureDate>
    </ownerSignature>
</ownershipDocument>
</XML>
</TEXT>
</DOCUMENT>
<DOCUMENT>
<TYPE>EX-24
<SEQUENCE>2
<FILENAME>cheshiremdholdingspoa2.htm
<DESCRIPTION>CHESHIRE MD HOLDINGS POA
<TEXT>
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd"><html><head>
<!-- Document created using Wdesk -->
<!-- Copyright 2021 Workiva -->
<title>Document</title></head><body><div id="if0d812446115483d8b2069efc66a3670_33"></div><div style="min-height:72pt;width:100%"><div style="text-align:right"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:700;line-height:120%">Exhibit 24.1</font></div></div><div style="margin-bottom:9pt;text-align:center"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:700;line-height:120%">POWER OF ATTORNEY</font></div><div style="margin-bottom:9pt;text-align:justify;text-indent:36pt"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:400;line-height:120%">KNOW ALL MEN BY THESE PRESENT, that I, Steve Phillips, hereby make, constitute and appoint each of Kathleen A. Waters, Samantha A. Caldwell, Stephanie N. Berberich and Ryan Fujikawa, acting individually, as my agent and attorney-in-fact for the purpose of executing in my name in my capacity as Vice President or in other capacities of Cheshire MD Holdings, LLC, a Delaware limited liability company, and each of its affiliates or entities advised or controlled by me or Cheshire MD Holdings, LLC, all documents, certificates, instruments, statements, filings and agreements (&#8220;documents&#8221;) to be filed with or delivered to any foreign or domestic governmental or regulatory body or required or requested by any other person or entity pursuant to any legal or regulatory requirement relating to the acquisition, ownership, management or disposition of securities, futures contracts or other investments, and any other documents relating or ancillary thereto, including, without limitation, all documents relating to filings with the United States Securities and Exchange Commission (the &#8220;SEC&#8221;) pursuant to the Securities Act of 1933, as amended, or the Securities and Exchange Act of 1934, as amended (the &#8220;Act&#8221;), and the rules and regulations promulgated thereunder, including, without limitation&#58; (1) all documents relating to the beneficial ownership of securities required to be filed with the SEC pursuant to Section 13(d) or Section 16(a) of the Act, including, without limitation&#58; (a) any acquisition statements on Schedule 13D or Schedule 13G and any amendments thereto, (b) any joint filing agreements pursuant to Rule 13d-1(k), and (c) any initial statements of, or statements of changes in, beneficial ownership of securities on Form 3, Form 4 or Form 5 and (2) any information statements on Form 13F required to be filed with the SEC pursuant to Section 13(f) of the Act.</font></div><div style="margin-bottom:9pt;text-align:justify;text-indent:36pt"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:400;line-height:120%">All past acts of the attorney-in-fact in furtherance of the foregoing are hereby ratified and confirmed.</font></div><div style="margin-bottom:9pt;text-align:justify;text-indent:36pt"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:400;line-height:120%">This Power of Attorney shall remain in effect until revoked, in writing, by the undersigned.</font></div><div style="margin-bottom:9pt;text-align:justify;text-indent:36pt"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:400;line-height:120%">IN WITNESS WHEREOF, the undersigned has executed this Power of Attorney, this 25th day of June, 2021.</font></div><div style="text-align:right;text-indent:252pt"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:400;line-height:120%;text-decoration:underline">&#47;s&#47; Steve Phillips</font></div><div style="text-align:right;text-indent:252pt"><font style="color:#000000;font-family:'Arial',sans-serif;font-size:10pt;font-weight:400;line-height:120%">Steve Phillips</font></div><div style="height:72pt;position:relative;width:100%"><div style="bottom:0;position:absolute;width:100%"><div><font><br></font></div></div></div></body></html>
</TEXT>
</DOCUMENT>
</SEC-DOCUMENT>
