Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GFGF for Samantha Borneman DC1635630122 11/1/21 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. | 1758909671 |
| Your Name | Paula Borneman |
| Email hidden; Javascript is required. | |
| Phone | (610) 683-7499 |
| Date of Birth | 02/22/1968 |
| Primary Member Name | PAULA BORNEMAN |
| List Family Members | David |
| Dentist Last Name | PAAT |
| Enter Office Code | 37975 |
| Address | 1137 Eagle Point Rd Kutztown, PA 19530 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX2173 |
| 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 | 10/31/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/01/2027 |
| Membership ID Number | 1792781896 |
| 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. *** |
