New (08/2022) Patients Subscriptions/Memberships

Subscriptions/Memberships

Talquin-Psychiatry.org
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Preferred Phone number

Area CodePhone Number
Mobile Carrier:
For SMS and Text Message Notifications ONLY (NO MARKETING or SPAM)
Personal Email
example@example.com
Subscription Options

(No insurance will automatically be charged $90 per visit, for those not enrolled in one of plans)

Monthly Subscription

To be paid on a monthly basis for visits, and/or refills

$80.00 for each month

Bi Weekly Subscription

To be paid on a bi weekly basis for visits, and/or refills

$45.00 for each two weeks

Subscriptions/Memberships