Wellness Savings Program
Disclaimer: THIS IS A DISCOUNT PROGRAM AND IS NONREFUNDABLE.  Consumer must understand that the Wellness Savings Card was an employee/employer only program that extended their benefits to the individual market and ONLY FREE to the Colonial employee benefit groups as additional benefits to their employees which is payable thru their employer. All applicants will be monitored thru the website if they are not employees of Colonial employee group enrollment. For more information, please visit our website at https://www.consultwithedmond.com/insurance-brokerage/wellness-dental-and-vision/.
Name *
Email *
Address *
Phone number *
DOB *
MM
/
DD
/
YYYY
Family Information
Name, date of birth, and relationship
Family member 1#
Family member 2#
Family member 3#
Family member 4#
Family member 5#
Dentist Name & Address
Membership
Sales Tax: 5%. $10 discount for Medicare.
Type of Membership *
Method of Payment *
Card Number
Card Expiration
CVV
Billing Zip Code
Comments
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy