Welcome Federal Employees & Retirees

Dentist Nomination Form

I would like to nominate the following dentist for consideration in the Dominion Dental network. I understand my name and the fact that I am a member may be used when contacting this dentist to inform him/her of this nomination. I also understand there may be instances where the dentist chooses not to participate with Dominion, or Dominion chooses not to accept the dentist's application due to stringent credentialing processes.

Your Information
First Name: *
Last Name: *
Dentist's Information
First Name: *
Last Name: *
Practice/Office Name: *
City: *
State: *
Phone: *
Please use the following format: XXX-XXX-XXXX
Plan Type:
Please enter "Select Plan (DHMO)"