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

New Patient 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.

New Patient Forms – Medicare Beneficiaries

Update Your Medical History

This form is for our current patients that need their annual medical history updated.

Medical History Forms

Notice of Privacy Policy

Please review the privacy policy, acknowledgment form, and release if you would like.

Release of Health Records

Authorization for use and disclosure of patient information

When you complete these forms and submit them, they will be securely submitted to our office and you may review those upon arrival.

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