Patient Registration-New Patient Forms

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

We strive to provide the highest quality state-of-the-art dental therapy, while individualizing treatment to each patient’s needs. Call us Today!
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Our Office Hours: Monday - Wednesday 8:00 AM - 5:00 PM, Thursday 8:00 AM - 3:00 PM, Friday 8:00 AM - 12:00 PM

Insurance/Guarantor Information Form

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 cover 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 office for release of records to another specified entity.

Established Patients of Record