Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Paid by Echeck 10/14/25 EK |
| 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. | DC1760452175 |
| Your Name | John Keller |
| Email hidden; Javascript is required. | |
| Phone | (352) 746-2339 |
| Date of Birth | 11/25/1947 |
| List Family Members | Susan |
| Referred by or Referral Code | ExMail 2-5-18 |
| Dentist Last Name | Lewis (A20815) |
| Address | 643 West Doerr Path Hernando, FL 34442 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX6180 |
| 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 | 12/07/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/07/2028 |
| Membership ID Number | 1792077333 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
