Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called in saying we’re a scam, office A20938 not honoring discount for a crown. They have DC custom ZGP. D6058 $1,280, matches with what he was charged. Was not happy with that, says we’re a scam and going to report us. Marking as no mail. 4/9/26 EK |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Thomas McHugh |
| Email hidden; Javascript is required. | |
| Phone | (440) 382-7301 |
| Date of Birth | 10/15/1958 |
| Enter Office Code | A20938 |
| Address | 2028 SOM Center Rd. Mayfield Hts., OH 44124 Map It |
| Payment Method | Credit Card |
| Credit Card | amex XXXXXXXXXXXX1625 |
| Total | $99.95 |
| 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 | 10/14/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/14/2027 |
| Membership ID Number | 1791947208 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
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