Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called to make sure that the office was notified that they were a member as of 9/13/16. According to QB office was notified on 9/14/16. 9/14/16 BH CASH20 Renew 9/2/2020 EK Dr. Michelle from A22511 EM'd to let us know member Nina lives in a separate household than below. Removed Nina from the family plan. 10/05/26 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. | 1757684686 |
| Your Name | Veronica Farchione |
| Email hidden; Javascript is required. | |
| Phone | (586) 206-9358 |
| Date of Birth | 06/01/1967 |
| List Family Members | Dominic Jr. |
| Referred by or Referral Code | CASH20 Renew 9/2/2020 |
| Enter Office Code | A22511 |
| Address | 51322 Westwood Dr. Macomb, MI 48042 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 | 10/20/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/20/2027 |
| Membership ID Number | 1790627095 |
| 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. *** |
| Payment Method | PayPal Checkout |
