Change Request Form

If you are already a member of Dental Direct and would like to make a change to your membership, please use the form below. For a printable version of the form below, please visit our download page.

* indicates a required field
Member Information

* Member ID:

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip:

* Date of Birth:

* Gender

* Home Phone:

Cell Phone:

* E-mail Address:

Marital Status:

Name Change
Old Name
First Name:

Last Name:

Relationship:

New Name
First Name:

Last Name:

Relationship:

Address Change

First Name:

Last Name:

Street:

City:

State:

Zip:

Add a Member

Additional Member Information
You may register a maximum of 4 financially dependent family members living in your household with each enrollment. To enroll more than 4 members, please contact us.

First Name:

Last Name:

Relationship:

First Name:

Last Name:

Relationship:

First Name:

Last Name:

Relationship:

First Name:

Last Name:

Relationship:

Remove a Member

First Name:

Last Name:

Relationship:

Cancel Dependant(s)
First Name:

Last Name:

Relationship:

Cancel Coverage – Termination of Employment
First Name:

Last Name:

Relationship:

Date of Termination:

Cancel Coverage
First Name:

Last Name:

Relationship:

Other
Acknowledgment

By checking this box, I acknowledge that I have read and understand the Legal Disclaimer Terms and Conditions pertaining to this Discount Membership Program.

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