Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Janet LVM. Called her back, got her signed up. She was given our number by a referring office, but not given a code. She seemed confused that we are not Dentemax directly. I was not pulling her up in our system, she said she had a previous Dentemax plan. I explained how our plan works. The office she goes to is 23609. She kept asking for a 16-digit number that the office said to get from us. I let her know her mship ID# and told her to have the office call us with any questions. But she wanted to go ahead and SU because there is an opening for an appointment tomorrow. 7/27/2020 MT Member getting call to renew, already did. Added space in primary. 12/31/25 MT Paid with CC in Stripe bc CC field is down on SU form. 10/20/26 MT |
| 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. | 1765206699 |
| Your Name | Janet Applebee |
| Email hidden; Javascript is required. | |
| Phone | (248) 444-9444 |
| Date of Birth | 05/19/1946 |
| Dentist Last Name | Folbe (GM7222) |
| Address | 2602 Oliver Road Royal Oak, MI 48073 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 02/03/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/03/2028 |
| Membership ID Number | 1792510186 |
| 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. *** |
