Test form Signups
| Status | Active |
|---|---|
| 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. | 1758137148 |
| Your Name | Georgia Adolini |
| Email hidden; Javascript is required. | |
| Phone | (717) 655-7275 |
| Date of Birth | 01/04/1955 |
| Referred by or Referral Code | Office Call In 9/17/25 |
| Enter Office Code | DC1101 |
| Address | 10405 S Mountain Rd Fayetteville, PA 17222 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4319 |
| 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 | 10/18/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/18/2027 |
| Membership ID Number | 1791415715 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 2 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
