Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member might want to cancel, trying to find a different OS in the area. Said some from the website are retiring, many others said they never heard of us. I explained the difference between DC & DenteMax, offered to call offices for her. She said she has an appointment with an office tomorrow, but if she doesn't like them she will probably call back to cancel 5/11/21 EK Member wanted to know what a cleaning would be with our plan, did not have procedure codes, gave her an idea for fee sched 170 and 100, DLN Chiapel was not pulling up on our website, but they are a RO, I let her know I was looking at other dentists since he was not appearing on my list. She said that none of the offices on our list know who we are. I explained that we utilize DM and she said she will mention that at her appt. 6/16/2021 MT CASH20 returned, updated address, resending. 9/8/26 EK Member did not get SU as they are still unsubbed in MC. I sent her an email manually from mine. 10/8/26 EK Member called to see if we can date her plan to start at a later date, just not sure which one. Told her we didn't sent mcards yet so we can change the start date but would need to know by Monday, 10/12. She said she would call us Monday morning. 10/09/26 MT She called back, I changed start date to 12/15. Updated on Mcard list 10/12/26 EK Called Dr. William Raney GP to explain the plan for member. Reached VM 10/22/26 EK |
| 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. | 1739820066 |
| Your Name | Tammy Albrecht |
| Email hidden; Javascript is required. | |
| Phone | (314) 602-1644 |
| Date of Birth | 11/14/1969 |
| Enter Office Code | 25174 |
| Address | 16455 WILDHORSE LAKE BLVD APT 339 Chesterfield, MO 63005 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX8313 |
| 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 | 12/15/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/15/2028 |
| Membership ID Number | 1791403679 |
| 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. *** |
