In-person dental request (Nevada)

Nevada Medicaid in-person dental visit request form

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

Please complete all fields. Fields marked as optional can be skipped.

Language

Member ID (optional)

First name

Last name

Are you pregnant?

Parent or guardian name if under 18

Phone

Preferred day

Preferred time (optional)

I agree to opt in to Liberty's text messaging and email program.