Patient Registration-New Patient Forms

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

Health History Form

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Insurance/Guarantor Information Form

• Insurance/Guarantor Form

Fill out if you have dental insurance or patient is under 18 years of age.

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

• Notice of Privacy Policy
• HIPPA Acknowledgement of PP

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

• Authorization for use and disclosure of patient information

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

Established Patients of Record

• Medical History Update (for existing patients ONLY)