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.
Click To Call
765-447-9319 Schedule Your
Appointment Online Patient
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
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.
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
- Medical History Update (for existing patients ONLY)