Member RegistrationTo view pricing information, scroll to the bottom of the page. Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthdate (MM/DD/YYYY) * MM DD YYYY The clinician has provided you with their recommendation. Please let us know if you have any questions! You may take a look at the pricing below. Which Service will you be choosing? * Psychiatry Therapy How often will you be receiving services? * Weekly Biweekly Monthly How long will your sessions be? * 75-minutes 60-minutes 45-minutes 30-minutes Preferred Appointment Day of the Week * Monday Tuesday Wednesday Thursday Friday What is your preferred appointment time? * Please provide us with a range of time and days of the week. Preferred Payment Frequency * Once per Month Twice per Month (if biweekly or weekly appts) Credit Card Number * This will be the card on file to pay for your appointments Credit Card Expiration Date * MM DD YYYY Credit Card Security Number * Is your billing address the same as your physical address? * Yes No If not, please provide your billing address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Phone Number * (###) ### #### What is your Pharmacy? * Pharmacy Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pharmacy Phone Number * (###) ### #### I understand that I will receive detailed messages via email from MUUD Health employees * Yes No I understand that MUUD Health commonly utilizes text messages as a form of correspondence (appt reminders, questions, relevant updates, etc.) * Yes No MUUD Health is an established out-of-network provider. Meaning, most insurances will not be able to directly cover session fees. MUUD’s billing department can provide an invoice (superbill) for processing reimbursements. I understand that terms * Yes No I understand that my card on file will be charged on my monthly or biweekly billing date unless I cancel my membership the month prior. * Members are held to their billing agreements until the end of the month. I.e if a client decides to terminate services on Jan. 15th, they will still be charged for the entire month of Jan & still have access to MUUD services until the end of the month. They will not be charged or scheduled in Feb. Yes No Initial * Date * MM DD YYYY Thank you!
