Patient Registration-New Patient Forms

Scott A. Reef, DDS, MSD and Justin J. Villanueva, DMD, MSD, DHL — Periodontal Associates of Lafayette IN

Insurance/Guarantor and Medical History Information Forms

Online Intake Forms

We have an “Opt-out” status with Medicare. We cannot file claims with Medicare, nor can our patients for treatment. Dental procedures are not normally covered under traditional Medicare.

Notice of Privacy Policy

Please review the privacy policy, acknowledgment form, and release as you will be asked to sign these forms digitally upon your first visit to our office.

Release of Health Records

Print, fill out, and mail, e-mail, or bring to the office for release of records to another specified entity.

Call Lafayette Office Phone Number 765-447-9319 with any questions about completing our registration forms.