Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member is mailing in a check to renew, wanted to make sure who to make the check out to and the amount. Sounded like she kept saying Dentalcard, so I spelled it out for her, no L. 4/29/2021 MT |
| Membership Type | Individual Plan ($99.95) |
| 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. | 1741634784 |
| Your Name | Bonnie Holman |
| Phone | (502) 735-7410 |
| Date of Birth | 05/11/1953 |
| Referred by or Referral Code | Fax 8/12/2014, ExMail 05/05/21, CASH20 Renew 3/10/25 |
| Enter Office Code | CK4952 |
| Address | 1447 Antique Dr, Apt 127 Lexington, KY 40511 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX2802 |
| Total | $99.95 |
| 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 | 11/19/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/19/2027 |
| Membership ID Number | 1790610822 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
