Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | resent email after adjusted names. / they called in same time i was doing this, got new email. all set. 09/09/24 JC Out of network dental office called to verify John (phone # 440-857-0680) 3/24/26 EK |
| 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. | 1757609352 |
| Your Name | John Bennet |
| Email hidden; Javascript is required. | |
| Phone | (216) 789-1126 |
| Date of Birth | 08/22/1958 |
| List Family Members | Elizabeth, Julia, Laura |
| Enter Office Code | GM3338 |
| Address | 1533 Arthur Ave Lakewood, OH 44107 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX5334 |
| Total | $139.95 |
| Go Green | Paperless Option | yes |
| 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 | 11/11/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/11/2027 |
| Membership ID Number | 1790184795 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
