SAOE Group Enrollment (11 to 40 members)
Please Note: You will need to allow pop-ups and redirects to use this form.
Step 1: Fill out the enrollment form below. Once you submit this form, you will be redirected to an AffiniPay payment page if paying by credit card.
Practice Name:
*
Practice Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Locations:
*
Number of Doctors at Practice
Practice Phone Number:
*
Please enter a valid phone number.
Practice Contact Name for Payment:
*
Practice Contact Email:
*
Number of Members for Group Enrollment:
*
Upload an Excel Spreadsheet with each member's name, title, email, & phone number -OR- use the boxes below to provide member information. (Please note: Cell phone numbers provided may be used to text membership and meeting updates.)
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Member #1 Name
First Name
Last Name
Member #1 Title
Member #1 Email
example@example.com
Member #1 Phone Number
Please enter a valid phone number.
Member #2 Name
First Name
Last Name
Member #2 Title
Member #2 Email
example@example.com
Member #2 Phone Number
Please enter a valid phone number.
Member #3 Name
First Name
Last Name
Member #3 Title
Member #3 Email
example@example.com
Member #3 Phone Number
Please enter a valid phone number.
Member #4 Name
First Name
Last Name
Member #4 Title
Member #4 Email
example@example.com
Member #4 Phone Number
Please enter a valid phone number.
Member #5 Name
First Name
Last Name
Member #5 Title
Member #5 Email
example@example.com
Member #5 Phone Number
Please enter a valid phone number.
Member #6 Name
First Name
Last Name
Member #6 Title
Member #6 Email
example@example.com
Member #6 Phone Number
Please enter a valid phone number.
Member #7 Name
First Name
Last Name
Member #7 Title
Member #7 Email
example@example.com
Member #7 Phone Number
Please enter a valid phone number.
Member #8 Name
First Name
Last Name
Member #8 Title
Member #8 Email
example@example.com
Member #8 Phone Number
Please enter a valid phone number.
Member #9 Name
First Name
Last Name
Member #9 Title
Member #9 Email
example@example.com
Member #9 Phone Number
Please enter a valid phone number.
Member #10 Name
First Name
Last Name
Member #10 Title
Member #10 Email
example@example.com
Member #10 Phone Number
Please enter a valid phone number.
Member #11 Name
First Name
Last Name
Member #11 Title
Member #11 Email
example@example.com
Member #11 Phone Number
Please enter a valid phone number.
Member #12 Name
First Name
Last Name
Member #12 Title
Member #12 Email
example@example.com
Member #12 Phone Number
Please enter a valid phone number.
Member #13 Name
First Name
Last Name
Member #13 Title
Member #13 Email
example@example.com
Member #13 Phone Number
Please enter a valid phone number.
Member #14 Name
First Name
Last Name
Member #14 Title
Member #14 Email
example@example.com
Member #14 Phone Number
Please enter a valid phone number.
Member #15 Name
First Name
Last Name
Member #15 Title
Member #15 Email
example@example.com
Member #15 Phone Number
Please enter a valid phone number.
Member #16 Name
First Name
Last Name
Member #16 Title
Member #16 Email
example@example.com
Member #16 Phone Number
Please enter a valid phone number.
Member #17 Name
First Name
Last Name
Member #17 Title
Member #17 Email
example@example.com
Member #17 Phone Number
Please enter a valid phone number.
Member #18 Name
First Name
Last Name
Member #18 Title
Member #18 Email
example@example.com
Member #18 Phone Number
Please enter a valid phone number.
Member #19 Name
First Name
Last Name
Member #19 Title
Member #19 Email
example@example.com
Member #19 Phone Number
Please enter a valid phone number.
Member #20 Name
First Name
Last Name
Member #20 Title
Member #20 Email
example@example.com
Member #20 Phone Number
Please enter a valid phone number.
Planning to enroll more than 20 members? Please provide the additional member names, member titles, emails, and phone numbers in the box below.
Do you plan to pay by credit card or check?
*
Credit Card
Check
Please click the button below to submit your group enrollment form.
You will then be redirected to Step 2: Submitting payment.
Submit
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