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Patient Information

dinka dental

New Patient Information Form

Please complete form below prior to your first appointment at Dinka Dental. Question? Please contact us.

Step 1 of 7 - Patient Info

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Patient's Contact Information

Patient's Name(Required)

Patient's Birthday(Required)

Patient's Phone(Required)

Patient's Address(Required)

Patient's Basic Information

Patients SS#(Required)

# of Dependents

Whom May We Thank for Referring You?

Emergency Contact:

What is the patient's gender?

Female

Female

Male

Male

What is the patient's marital status?

Divorced

Divorced

Married

Married

Single

Single

Separated

Separated

Widowed

Widowed

Is the patient currently employed?

Employed - Yes

Yes

Employed - No

No

Does the patient have dental insurance?

Insurance - Yes

Yes

Insurance - No

No

Spouse's Information

Spouse's Full Name

Spouse's Employer

Spouse's Social Security #

Patient's Employer Information

Employer's Name

Employer's Phone

# of Yrs Employed

Employer's Address

Payment Information

Who is the financially responsible party for this account? (This will be the name listed on your billing statements)

Who Will Pay - Self

Self / I am

Who Will Pay - Parent or Guardian

Parent or Guardian

Who Will Pay - Spouse

My Spouse

Financially Responsible Party's Information

Responsible Party's Full Name

Responsible Party's Birthdate

Responsible Party's SS#

Phone

Address

Responsible Party's Employer

# of Years with Employer

Work Phone #

Employer's Address

What is the responsible party's gender?

Responsible Party - Female

Female

Responsible Party - Male

Male

Dental Insurance Information

Subscriber's Full Name

Subscriber's Birthdate

Subscriber's SS#

Subscriber's Employer

Employer's Address

Name of Insurance Provider

Group Number

Max Benefit Amount

Benefit Year

Is there a deductible?

Deductible Yes

Yes

Deductible No

No

What is the patient's relationship to the subscriber?

Relationship to Subscriber - Self

Self

Relationship to Subscriber - Spouse

Spouse

Relationship to Subscriber - Dependent

Dependent

Have you used your dental insurance previously?

Used Dental Insurance Previously - Yes

Yes

Used Dental Insurance Previously - No

No

Have you have additional / secondary dental insurance coverage?

More Than 1 Dental Plan - Yes

Yes

More Than 1 Dental Plan - No

No

Additional / Secondary Dental Insurance Information

Subscriber's Full Name

Relationship to Patient

Subscriber's Birthday

Subscriber's SS#

Subscriber's Employer

Name of Insurace Provider

Group Number

Patient's Health Information & History

Physician's Name

Date of Last Physical

Physician's Address

How is your/the patient's general health?

General Health - Excellent

Excellent

General Health - Good

Good

General Health - Fair

Fair

General Health - Poor

Poor

Currently taking prescription medication?

Taking Meds - Yes

Yes

Taking Meds - No

No

Brief Purpose for Medication

Treated for heart disease?

Heart Disease - Yes

Yes

Heart Disease - No

No

Diagnosed with a heart murmur?

Heart Murmur - Yes

Yes

Heart Murmur - No

No

Diagnosed with rheumatic fever?

Rheumatic Fever - Yes

Yes

Rheumatic Fever - No

No

Diagnosed with jaundice?

Jaundice - Yes

Yes

Jaundice - No

No

Diagnosed with abnormal blood pressure?

Abn Blood Pressure - Yes

Yes

Abn Blood Pressure - No

No

Diagnosed with asthma?

Asthma - Yes

Yes

Asthma - No

No

Diagnosed with ulcers?

Ulcers - Yes

Yes

Ulcers - No

No

Have sinus issues?

Sinus Trouble - Yes

Yes

Sinus Trouble - No

No

Diagnosed with tuberculosis?

Tuberculosis - Yes

Yes

Tuberculosis - No

No

Treatment for cough?

Cough - Yes

Yes

Cough - No

No

Diagnosed with diabetes?

Diabetes - Yes

Yes

Diabetes - No

No

Diagnosed with epilepsy?

Hep -Yes

Yes

Hep - No

No

Diagnosed with hepatitis?

Epilepsy - Yes

Yes

Epilepsy - No

No

Diagnosed with arthritis?

Arthritis - Yes

Yes

Arthritis - No

No

Diagnosed with anemia?

Anemia - Yes

Yes

Anemia - No

No

Diagnosed with a stroke?

Stroke - Yes

Yes

Stroke - No

No

Diagnosed with heart lesions?

Heart Lesions - Yes

Yes

Heart Lesions - No

No

Diagnosed with glaucoma?

Glaucoma - Yes

Yes

Glaucoma - No

No

Diagnosed with a venereal disease?

VD - Yes

Yes

VD - No

No

Been involved in a serious accident?

Serious Accident - Yes

Yes

Serious Accident - No

No

Diagnosed with HIV/AIDS?

Aids - Yes

Yes

Aids - No

No

Treated (other than diagnostic) with x-ray?

Treated w X Ray - Yes

Yes

Treated w X Ray - No

No

Allergic to any of the following? (check all that apply)

Allergic - Codeine

Codeine

Allergic - Penicillin

Penicillin

Allergic -Local Anesthesia

Local Anesthesia

Allergic - Other Meds

Other Meds

Allergic to:(Required)

Ever had prolonged bleeding?

Prolonged Bleeding - Yes

Yes

Prolonged Bleeding - No

No

Ever had fainting spells?

Fainting - Yes

Yes

Fainting - No

No

Is the patient pregnant?

Pregnant - Yes

Yes

Pregnant - No

No

How Far Along in Pregnancy?

Patient's Dental Information & History

Dentist's Name

Dentist's Phone

Date of Last Dental Visit

Dental x-rays taken?

Exray - Yes_es_:signature

Yes

Xray - No

No

All teeth x-rayed in the past 3 years?

Teeth Xray - Yes

Yes

Teeth Xray - No

No

Does the patient have dentures?

Dentures - Yes

Yes

Dentures - No

No

Age of Dentures

Family history of dentures?

Family History of Dentures - Yes

Yes

Family History of Dentures - No

No

Dissatisfied with how teeth look?

Dissatisfied w Look - Yes

Yes

Dissatisfied w Look - No

No

Previous orthodontic treatment?

Ortho - Yes

Yes

Ortho - No

No

Clench or grind teeth?

Clench or Grind - Yes

Yes

Clench or Grind - No

No

Pain in jaw, face or ears?

Face or Jaw Pain - Yes

Yes

Face or Jaw Pain - No

No

Jaw makes a clicking sound?

Jaw Click - Yes

Yes

Jaw Click - No

No

Ever have trouble opening mouth?

Trouble Opening - Yes

Yes

Trouble Opening - No

No

Unpleasant odor or taste in mouth?

Bad Taste or Odor - Yes

Yes

Bad Taste or Odor - No

No

Diagnosed with gum disease or pyorrhea?

Gum Disease or Pyorrhea - Yes

Yes

Gum Disease or Pyorrhea - No

No

Bleeding gums?

Bleeding Gums - Yes

Yes

Bleeding Gums - No

No

Teeth sensitive to cold?

Sensitive to Cold - Yes

Yes

Sensitive to Cold - No

No

Teeth sensitive to pressure?

Sensitive to Pressure - Yes

Yes

Sensitive to Pressure - No

No

Teeth sensitive to heat?

Sensitive to Hot - Yes

Yes

Sensitive to Hot - No

No

Does food catch between teeth?

Food Between Teeth - Yes

Yes

Food Between Teeth - No

No

Is there anything else the doctor should be aware of?

Patient Signature(Required)

dinka dental

Patient Reviews & Testimonials

blue quotes

I highly recommend this dentist office. Doctors John and Cathy Dinka are the best. The whole staff rocks. Have been going here for 21+ years. They have serviced me and my children and now my grandson who’s now 4. Family

…

I highly recommend this dentist office. Doctors John and Cathy Dinka are the best. The whole staff rocks. Have been going here for 21+ years. They have serviced me and my children and now my grandson who’s now 4. Family dentistry at its best!

show more “Phyllis Review of Dinka Dental”

- Phyllis -

After a bad experience at a previous dentist I switched to Dinka Dental at the recommendation of a friend. I have had a great experience at this office. I have had appointments with both Dr. Catherine and Dr. John (a

…

After a bad experience at a previous dentist I switched to Dinka Dental at the recommendation of a friend. I have had a great experience at this office. I have had appointments with both Dr. Catherine and Dr. John (a husband and wife dentistry team) and both are great as well as rest of the staff. If you are looking for a dentist I recommend this office.

show more “Rebecca Soisson Review of Dinka Dental”

- Rebecca Soisson -

I hated going to the dentist until coming to Dinka Dental. Both Drs are amazing as well as their assistants especially Shelley and beyond friendly front desk staff. Love working with Paula. From the first phone call, you are truly

…

I hated going to the dentist until coming to Dinka Dental. Both Drs are amazing as well as their assistants especially Shelley and beyond friendly front desk staff. Love working with Paula. From the first phone call, you are truly taken care of from start to finish. They are truly the best.

show more “Lissa Volz Review of Dinka Dental”

- Lissa Volz -

This is the best dental office from the front to the back! Hands down. Everyone is wonderful here. Absolute lifeshow more “Heather Malcolm Review of Dinka Dental”

- Heather Malcolm -

Always a pleasure. Everyone is respectful, polite, and make sure you areshow more “Wendy Wright Review of Dinka Dental”

- Wendy Wright -

Dr. Cathy and Dr. John are two of the most caring medical professionals I have ever met. I personally see Dr. John, but have been a patient of Dr. Cathy on occasion. She is always concerned for her patients comfort.

…

Dr. Cathy and Dr. John are two of the most caring medical professionals I have ever met. I personally see Dr. John, but have been a patient of Dr. Cathy on occasion. She is always concerned for her patients comfort. When at their office you can feel the friendly atmosphere amongst all the employees and patients alike. It starts when you arrive, well now, in the parking lot. They ask about my grandchildren, how my wife is doing in her back surgery recovery, you just become part of their family. Dr. Cathy and Dr. John come with my highest admiration and recommendation as medical professionals.

show more “Dan Fredericks Review of Dinka Dental”

- Dan Fredericks -

Absolutely amazing! Dr. Dinka has worked with me for almost 2 years to address the MANY problems my teeth have. The work is spot on. The office staff are wonderful. I don’t have dental insurance and they’ve patiently worked with

…

Absolutely amazing! Dr. Dinka has worked with me for almost 2 years to address the MANY problems my teeth have. The work is spot on. The office staff are wonderful. I don’t have dental insurance and they’ve patiently worked with me on finances and I couldn’t be more grateful.

show more “Jenna V Review of Dinka Dental”

- Jenna V -

This dentist is amazing! Clean facility and the staff is just as pleasant as they wanna be. Kid friendly and interacts with the children. If you have been to a dentist for awhile they make you feel like they’ve known

…

This dentist is amazing! Clean facility and the staff is just as pleasant as they wanna be. Kid friendly and interacts with the children. If you have been to a dentist for awhile they make you feel like they’ve known you for years with the knowledge and welcoming atmosphere. I would recommend this place most definitely.

show more “Ruth Hatcher Review of Dinka Dental”

- Ruth Hatcher -

I’m absolutely enthralled by the amazing doctors and wonderful assistants I’ve met there! Only been there a few times, but the atmosphere and camaraderie makes me feel like we’re old friends! I will continue to remain a patient as long

…

I’m absolutely enthralled by the amazing doctors and wonderful assistants I’ve met there! Only been there a few times, but the atmosphere and camaraderie makes me feel like we’re old friends! I will continue to remain a patient as long as you’ll have me! Oh, and make sure you have plenty of nitrous oxide whenever I visit you….LOL!!!

show more “Susan Nelson Review of Dinka Dental”

- Susan Nelson -

I LOVE THIS OFFICE! The Staff and the Doctors are amazing! They are all top of the line professionals. Dr. Dinka listens to your concerns and gives his professional and honest opinion before making any decisions. All the Doctors are

…

I LOVE THIS OFFICE! The Staff and the Doctors are amazing! They are all top of the line professionals. Dr. Dinka listens to your concerns and gives his professional and honest opinion before making any decisions. All the Doctors are meticulous and very attentive to your needs. I’ve had many emergency dental issues throughout the years and the staff has always been accommodating and caring to my needs. I recommend this office constantly and will continue to tell everyone about this 5 star office! They make you feel like family : )

show more “K Dyer Review of Dinka Dental”

- K Dyer -

So grateful I was referred to Dinka Dental. I have gone 3 times now and have had nothing but amazing things to say. Staff is always kind, professional and welcoming. I will never go to another dentist’s office again. I

…

So grateful I was referred to Dinka Dental. I have gone 3 times now and have had nothing but amazing things to say. Staff is always kind, professional and welcoming. I will never go to another dentist’s office again. I recommend them to anyone and everyone.

show more “Heather Pinch Review of Dinka Dental”

- Heather Pinch -

When I come to Dinka Dental, I don’t get the feel of an ordinary dental office, the ladies at the front desk make it worth your time being there within the first 10 minutes, and the staff is so friendly

…

When I come to Dinka Dental, I don’t get the feel of an ordinary dental office, the ladies at the front desk make it worth your time being there within the first 10 minutes, and the staff is so friendly and caring, overall I can see myself bringing my future children to Dinka Dental.

show more “Justin Miner Review of Dinka Dental”

- Justin Miner -

There are dentists on every corner in Sterling Heights. I prefer Dinka Dental. From their office staff, Debbie and Paula who are smart and professional and witty and warm to my favorite hygienist, Cheryl, whom I’ve gotten to know and

…

There are dentists on every corner in Sterling Heights. I prefer Dinka Dental. From their office staff, Debbie and Paula who are smart and professional and witty and warm to my favorite hygienist, Cheryl, whom I’ve gotten to know and really respect, to my favorite dentist, Dr. John who is gentle as the day is long, this is my place to go for my oral hygiene and professional opinion regarding my teeth. The office is clean and the view looking out the windows is beautiful. Just do them a favor, FLOSS! Just kidding, they don’t yell that!

show more “Patrice Review of Dinka Dental”

- Patrice -

Very friendly and willing to work out a payment plan with you. I don’t like dentists from previous experiences plus who likes going to the dentist right. But they take the time to make you feel comfortable and that you

…

Very friendly and willing to work out a payment plan with you. I don’t like dentists from previous experiences plus who likes going to the dentist right. But they take the time to make you feel comfortable and that you don’t feel any pain during your visit. Also if you do they don’t just keep going they stop and address it so you don’t feel it at all. Glad we found this dentist office.

show more “Nick Siebenborn Review of Dinka Dental”

- Nick Siebenborn -

Excellent experience very professional staff and very informative and kindly and friendlyshow more “Asmeth Canales Review of Dinka Dental”

- Asmeth Canales -

Read More | Write a Review

CONTACT

Dinka Dental

Address

35100 Tiffany Drive
Suite 101
Sterling Heights, MI 48312

Office Phone

586-939-5800

Emergencies Only

586-214-7264

Hours

Mon-Thu | 8:30 a - 7 p
Fri | 8:30 a - 1 p
Sat | By Appointment

Email

appointments@dinkadental.com

Email

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