Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | ExMail 1/29/19, ExMail 07/07/23, ExMail 08/02/24, ExMail 08/07/2025, |
| 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. | 1754595408 |
| Your Name | Kay Whitsel |
| Email hidden; Javascript is required. | |
| Phone | (717) 496-7438 |
| Date of Birth | 05/26/1958 |
| Referred by or Referral Code | ExMail 09/29/26 |
| Dentist Last Name | Zimmerman (DC1101) |
| Address | P.O. Box 301 South Mountain, PA 17261 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 10/16/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/16/2027 |
| Membership ID Number | 1790698042 |
| 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. *** |
