Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called in because her dental office was closed for 2 months and they reopened today she said. She wanted to know if we are extending anyone mship since she had to cancel her previous appts due to COVID-19. I let her know our policy is to extend their plans, etc. She confirmed that the office code used to SU is still their dental office. 5/18/2020 MT Flora called in regarding the COVID-19 project. I tried to get her to renew & explained that we would add the time to her renewal, but she said she already knows the dates the office was closed from, & wants it added to her current membership first. I tried to explain that she was on the list & that a different dept was handling it, & to check back closer to her exp date, but she requested that we expedite it. Wanted something in writing by EM saying that we are working on it. I told her I would put in a request 5/26/20 EK Member requested senior discount. 5/12/2021 MT Member wanted $10 waived, asked it to start tomorrow. 06/06/25 MT Member requested senior discount. 10/07/26 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. | 1749225338 |
| Your Name | Gustav Faverman |
| Email hidden; Javascript is required. | |
| Phone | (913) 451-3403 |
| Date of Birth | 01/29/1946 |
| List Family Members | Flora |
| Enter Office Code | A20843 |
| Administrative Code | 10PERCENT |
| Address | 12301 Russell St Overland Park, KS 66209 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3276 |
| Total | $125.95 |
| 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 | 10/07/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/07/2027 |
| Membership ID Number | 1791393794 |
| 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. *** |
