Patient Registration
Patient Is:
Responsible Party (If someone other than patient)
Patient Information
Gender:
Marital Status:
Primary Insurance Information
Patient Relationship to Insured:
Secondary Insurance Information
Patient Relationship to Insured:

Medical History

Please fill out this form and hit the Submit button at the bottom of the page.
It will be securely sent to our office.

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Please check the "Yes" box below for all that apply. You can uncheck it by clicking in the checkbox again.

Woman: Are You

Are you allergic to any of the following? Please check any that apply

Do you have, or have had, any of the following?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Andrea N. Leinassar, D.D.S.
Scott Leinnassar, D.M.D.

Dental History

How would you rate the condition of your mouth?
I routinely see my dentist every:
PLEASE ANSWER YES OR NO TO THE FOLLOWING
Yes
No

PERSONAL HISTORY

1. Are you fearful of dental treatment?
2. Have you had an unfavorable dental experience?
3. Have you ever had complications from past dental treatment?
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
6. Have you had any teeth removed or missing teeth that never developed?

SMILE CHARACTERISTICS

7. Is there anything about the appearance of your teeth that you would like to change?
8. Have you ever whitened (bleached) your teeth?
9. Have you felt uncomfortable or self-conscious about the appearance of your teeth?
10. Have you been disappointed with the appearance of previous dental work?

BITE AND JAW JOINT

11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
12. Do you / would you have any problems chewing gum?
13. Do you / would you have any problems chewing bagels, protein bars, or other hard foods?
14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
15. Are your teeth crowding or developing spaces?
16. Do you have more than one bite and squeeze to make your teeth fit together?
17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
18. Do you clench your teeth in the daytime or make them sore?
19. Do you have any problems with sleep or wake up with an awareness of your teeth?
20. Do you wear or have you ever worn a bite appliance?

TOOTH STRUCTURE

21. Have you had any cavities within the past 3 years?
22. Does your mouth always seem dry or do you have difficulty swallowing any food?
23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
24. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
25. Do you have grooves or notches on your teeth near the gum line?
26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
27. Do you frequently get food caught between any teeth?

GUM AND BONE

28. Do your gums bleed or are they painful when brushing or flossing?
29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
30. Have you ever noticed an unpleasant taste or odor in your mouth?
31. Is there anyone with a history of periodontal disease in your family?
32. Have you ever experienced gum recession?
33. Have you ever had any teeth become loose on their own (without an injury)?
34. Have you experienced a burning sensation in your mouth?

Consent Form

Andrea N. Leinassar D.D.S. PLLC
Smith Valley Smiles
2311 State Route 208   P.O. Box 305   Smith, NV 89430

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Effective Date: September 1, 2026

Open / Download Privacy Notice (PDF)

OUR LEGAL DUTY

This notice describes how Smith Valley Smiles may use and disclose your Protected Health Information (PHI) and your rights regarding that information. PHI includes information that identifies you and relates to your past, present, or future physical or mental health condition, dental treatment, or payment for health care services.

We are required by federal law under the Health Insurance Portability and Accountability Act (HIPAA), including the HIPAA Privacy Rule, Security Rule, and the HIPAA Omnibus Rule, to maintain the privacy and security of your protected health information.

We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information as required by federal breach notification laws.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Treatment

We may use and disclose your health information to provide, coordinate, or manage your dental care. For example, we may share information with dental specialists, physicians, laboratories, or pharmacies involved in your care.

Payment

We may use and disclose your health information to obtain payment for treatment and services. This may include submitting claims to dental insurance companies, verifying benefits, and collection activities.

Healthcare Operations

We may use and disclose your health information for administrative and operational purposes such as quality assessment, staff training, licensing, accreditation, and compliance reviews.

OTHER PERMITTED DISCLOSURES

We may disclose health information without written authorization in certain situations including:

  • Appointment reminders
  • Treatment alternatives or health-related benefits
  • Individuals involved in your care
  • Public health reporting
  • Health oversight activities
  • Legal proceedings or court orders
  • Law enforcement requests
  • Situations required by federal, state, or local law

NEVADA SPECIFIC PRIVACY PROTECTIONS

Nevada law may provide additional privacy protections beyond federal HIPAA regulations. Under Nevada law, certain health information may require additional authorization before disclosure, including information related to HIV/AIDS, substance abuse treatment, mental health treatment, and genetic testing results.

Nevada Revised Statutes (NRS) also require health care providers to maintain the confidentiality of patient records and limit disclosures without patient consent except where specifically authorized by law.

USES AND DISCLOSURES REQUIRING AUTHORIZATION

Certain uses or disclosures require your written authorization including:

  • Marketing communications where the practice receives financial compensation
  • Sale of protected health information
  • Most uses of psychotherapy notes (if applicable)
  • Any uses not described in this notice, you may revoke your authorization at any time in writing.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights under HIPAA:

  • Right to Inspect and Copy — You may request copies of your health records.
  • Right to Request Restrictions — You may request limits on certain uses or disclosures.
  • Right to Request Confidential Communications — You may ask us to contact you in a specific way.
  • Right to Amend — You may request correction of inaccurate or incomplete information.
  • Right to an Accounting of Disclosures — You may request a list of certain disclosures.
  • Right to a Paper Copy — You may obtain a paper copy of this notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You will not be retaliated against for filing a complaint.

CONTACT INFORMATION

Privacy Officer: Andrea N. Leinassar
Phone: 775-465-2388
Practice Name: Andrea N. Leinassar DDS
Address: PO Box 305 2311 ST R 208

Notice of Privacy Practices Acknowledgement and Patient Consent Form

Notice effective date: September 1, 2026

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  • Conduct plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality of assessments and physician certifications.
  • Make confirmation phone calls to patients on the day before their appointment.

I authorize the staff of Andrea N. Leinassar, D.D.S. to leave a message on my answering machine regarding:

My Appointment
My Dental Care
My Patient Account

Also, if I am not available, I authorize the staff of Andrea N. Leinassar, D.D.S. to speak with the individual(s) listed below regarding my care.

I authorize the staff of Andrea N. Leinassar, D.D.S. to call my work number, if I am not available.
I also authorize the staff of Andrea N. Leinassar, D.D.S. to leave a message on my voice mail at my work number.

I have received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change it's Practices from time to time and that I may contact this organization at any time at the address above to obtain my current copy of the Notice of Privacy Practices

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Andrea N. Leinassar, D.D.S.
Scott Leinassar, D.M.D.
General Dentistry

2311 Hwy 208   *   P.O. Box 305 Smith, NV 89430   *   Telephone (775) 465-2388

Financial Agreement

Please fill out this form and hit the Submit button at the bottom of the page.
It will be securely sent to our office.

  1. I understand that although I may own one or more insurance policies, I, not the insurance companies, am responsible for payment of all charges incurred for my treatment by Andrea N. Leinassar D.D.S. and/or Scott Leinassar, D.M.D., and also that my account will be paid at each appointment unless I make other arrangements with this office. I will pay in full the charges in the following manner:
    *Fees May Apply
    *Fees May Apply
  2. Balance is due and payable in full 10 days from statement date. A finance charge of 2% per month, 24% per year or a minimum of $2.50 will be charged to accounts with a balance of over 30 days. A service/re-billing fee of $7.50 will be charged to the account when no payment is made or terms of the contract agreement are not met. Please contact our office if you are unable to meet the above terms. Allowances will be made while processing insurance claims up to six weeks. A fee of $25.00 will be charged on all returned checks. I understand that if my account is assigned to a collection agency, that the collection agency will charge a commission or fee that may be as much as %50 of the amount I owe. I understand that if my account is assigned to a collection agency that Andrea Leinassar, D.D.S. PLLC may add the amount of the collection agency's commission or fee to the amount that I owe, and I agree to pay that additional amount.
  3. I understand and agree that in the event legal action is commenced to enforce my obligations hereunder, that I will pay court costs and reasonable attorney's fees.
  4. A 24 business hour notice is required in the event you need to change your appointment day or time. If 24 business hour notice is not given you will be charged a $50 "Late-Cancel/No Show" fee.

Patient, Parent, or Guardian if Patient is a minor

Authorization to Pay Benefits to Dentist:

I hereby authorize and assign all payments directly to Andrea N. Leinassar D.D.S. for all dental benefits otherwise payable to me for services. Consent is hereby granted to use this digital or photostatic copy as equally valid authorization.

Patient, Parent, or Guardian if Patient is a minor

Dental Anesthesia Consent Form

SMITH VALLEY SMILES

ANDREA N. LEINASSAR, D.D.S.
SCOTT LEINASSAR, D.M.D.
FAMILY DENTISTRY

2311 HIGHWAY 208
P.O. BOX 305 SMITH, NV 89430
(775) 465-2388

Dental Anesthesia

Anesthetics are frequently used in most dental procedures; commonly used for most restorative and surgical procedures. Different anesthetics may be used based on your needs, length of needed anesthesia, or medical history issues. All anesthetics used in this office will be of "local delivery" only and will involve injections for infiltration, or nerve blocks. There are risks associated with injections of anesthetics into the mouth that range from allergic reactions, to traumatic injuries to nerves and blood vessels. Great effort is made to minimize these risks. you must advise us if you encounter, or have encountered, any unusual reactions to any anesthetic, or injection.

I understand that I will be given a local anesthetic injection and that in rare situations patients have had an allergic reaction to the anesthetic, an adverse medication reaction to the anesthetic, or temporary or permanent injury to nerves and or blood vessels from the injection. I understand that the injection area(s) may be uncomfortable following treatment and that my jaw may be stiff and sore from the anesthetic injection.

Processing