Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Via chat, member looking for dentist in area, offices aren’t familiar with DC. Mentioned DM, offered to reach out, will give her a call once I reach some offices. Called office and spoke with Grace, explained DM, she verified they are in DM, patient can call and make an appt. I let member know. 12/09/2022 MT |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | Yes |
| Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card. | 1753456169 |
| Your Name | Kevin Kidd |
| Email hidden; Javascript is required. | |
| Phone | (313) 618-4959 |
| Date of Birth | 06/23/1954 |
| List Family Members | Joyce Peralta |
| Dentist Last Name | Mashni (DC352) |
| Address | 16176 Wetherby Street Beverly Hills, MI 48025 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX8964 |
| Total | $139.95 |
| Go Green | Paperless Option | not |
| Terms |  I have read the Terms and Conditions and wish to purchase the Discount Medical Plan. |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 09/27/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/27/2027 |
| Membership ID Number | 1789587348 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
