Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member LVM, Eric called back. Spoke w/ member. He wanted to make sure he signed up correctly and that his dentist was in network, DLN Obermeier. I explained that he did and I pulled up his dentist on our website. He did not have a flyer or office code, but it was this office below. 09/17/26 MT |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Stephen Brown |
| Email hidden; Javascript is required. | |
| Phone | (216) 233-2423 |
| Date of Birth | 04/22/1939 |
| List Family Members | Lesley Maunsell Brown |
| Address | 7065 Wick Lane, #108 Chagrin Falls, OH 44023 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX5424 |
| 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 | 09/17/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/17/2027 |
| Membership ID Number | 1789649702 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
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