Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Scott contacted via chat to add Nicholas Plummer to plan 6/4/20 EK Same as last year, IND or FAM? 12/20/21 JC A22511 sent EM saying Nicholas and Alexandra in different household, removing them from plan. 09/15/25 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. | 1757939703 |
| Your Name | Ann Plummer |
| Email hidden; Javascript is required. | |
| Phone | (248) 417-4911 |
| Date of Birth | 09/05/1965 |
| List Family Members | Nick, Scott Jr, Brett (all Leonard) |
| Dentist Last Name | Dziurgot (A22511) |
| Address | 18741 San Jose Blvd Lathrup Village, MI 48076 Map It |
| Payment Method | PayPal |
| Total | $139.95 |
| 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 | 1792070173 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 12 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
| Payment Method | PayPal Checkout |
