Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Via Jon: Office: A21895 Member called in saying we quoted her discounts and her OS quoted her at higher rates, also wanting to compare with another OS. I explained pricing varies from year to year, office to office etc. She did not have procedure codes. I looked up Dr.'s to look up examples for extractions. The one OS was listed on our site, but not at the location she described. She gave up on the call after this. I checked but did not see evidence of quote requests in our emails so must have called at some point. 5/11/26 EK GFGF for Patricia Guotana DCDC1781626511 6/116/26 EK |
| 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. | 1750192996 |
| Your Name | Marla Bentley |
| Email hidden; Javascript is required. | |
| Phone | (248) 765-7004 |
| Date of Birth | 12/27/1964 |
| Enter Office Code | A21895 |
| Address | 1391 Maple Dr Rochester, MI 48307 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4687 |
| 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 | 10/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/21/2027 |
| Membership ID Number | 1792589044 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
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