Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Took this SU on the phone. Said she used to be a member with us years ago and then her dentist no longer accepted. 10/20/26 MT Per my contact EM’s it was office GM4688. Entering Ref. 10/20/26 EK |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Susan Wearsch |
| Phone | (440) 985-8147 |
| Date of Birth | 12/22/1944 |
| Enter Office Code | GM4688 |
| Address | 860 Jefferson St Vermilion, OH 44089 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX3633 |
| 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 | 10/20/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/20/2027 |
| Membership ID Number | 1792523752 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
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