Join – Patient Choice Coalition

Membership Form

Please fill out the information below.

Company Name(s) *

Membership Type *

*Suggested Rate $1,000 – $10,000 per month

ASC’s, Hospitals, or Healthcare Facilities Association(s) Organizations with 2 or more facilities Patient Membership $10/mo Contribution

Negotiated Monthly Rate

Individual Physician

$100 Bronze Membership $200 Silver Membership $400 Gold Membership $500 Platinum Membership

Address

Phone

Company Email

Website

Contact Name for Invoicing

Contact Email for Invoicing

Primary Contact Name *

Primary Contact Email *

Person(s) to receive all Patient Choice Coalition correspondence, email addresses and/or cell # to receive text

Please add line break before each new contact

Additional information/comments

Agreement (Please check the box below)

Make all checks payable to:
Patient Choice Coalition
519 N. Country Club Rd.
Muskogee, OK 74403.
If paying by Credit Card, please contact:
Dan Chepkauskas at 832-877-0800

I agree to the terms above