Subscriptions/Memberships
Talquin-Psychiatry.org
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Phone number
*
-
Area Code
Phone 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)
No set up fee, set pricing.
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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
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