Test form Signups
| Status | Canceled |
|---|---|
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| Plan Canceled |
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| Misc Member Notes | How did they hear about us? EM sent / emailed back and said DC1101. This office no longer takes DC. Entering into QB as member info note. 09/28/2026 EK Member called. She said 6 months ago they were told by DC1101 that they take DC, but when she got to her appointment this week, she was told they do not. She does not want to go elsewhere and wants a refund. 10/1/26 EK EM'd Adam to refund in paypal. 10/02/26 MT Adam was out of town, he EM'd today that he refunded $129.95 in Paypal. 10/07/26 MT |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Mary Millin |
| Email hidden; Javascript is required. | |
| Phone | (301) 526-1323 |
| Date of Birth | 01/19/1965 |
| List Family Members | Brian |
| Address | 13654 Lower Edgemont Rd Waynesboro, PA 17268 Map It |
| Payment Method | PayPal |
| 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 | 09/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/28/2027 |
| Membership ID Number | 1790610780 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| Opt out of automated reminder calls |
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| Stop Sending Mail (No Mailer) |
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| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
| Payment Method | PayPal Checkout |
