Member Confirmation of Protection Request

If you are a dentist requesting confirmation of your malpractice protection on behalf of a third party, fill out the form below. 

Member Information

Provide your name and RCDSO member I.D. number. Your name should match your RCDSO registration details. 

Optional

Member Consent 

We require your written consent to release confirmation of your malpractice protection. Download and fill out the member consent form. Attached the completed form below. 

Supported Files: .doc, .docx, .pdf, .jpg, .png, .txt

Request Details

Provide the details of the third party requesting confirmation of your malpractice protection and how they prefer to receive the letter. 

Requesting

Confirmation of Protection
Optional
Optional
Additional Information Optional

 Provide any additional details regarding your request for confirmation of protection.