In-Person Dental Request

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NOTICE: LIBERTY Dental Plan systems will undergo scheduled maintenance and a Disaster Recovery exercise from Friday, June 12 at 8:00 PM (PST) through Monday, June 15 at 4:00 AM (PST). Our Services may be temporarily unavailable or display a maintenance page during this time.

In Person Dental Visit Request Form

Please complete the following form to request your in person dental visit.

Member Number (optional)

First Name

Last Name

Parent / Guardian Name if Under 18

State

Cell Phone #

Invalid format

Email Address

Invalid format

Preferred Day (optional)

Preferred Times

I agree to opt-in to LIBERTY's text messaging and email program

Yes

Please only click Submit once