(08) 9300 0600

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Make an Appointment

Please select an option below to continue with this form.

Are you a referring dental practitioner? Yes No

This form is for dentists to refer to their clients. If you would like to make an appointment for your child please use the this form.

Referral to

Please select your preferred dental provider Marilyn Lobo - Specialist Paediatric Dentist
Susan Wong - Specialist Paediatric Dentist
Judy Ottaway - Dental Therapist

Patient Details

First Name *

Last name *

Date of Birth

Address

Contact number *

Parent / Guardian

Medical History

Dental History

Radiographic History

Does the patient have private health insurance? Yes No

Insurer

Does the patient have a Health Care Card? Yes No

Reason for referral

How may we be of service? Pain
Dental Caries
Hypomineralisation/Hypoplasia
Dental Anomalies
Trauma
Other

Comments

Referring Dental Practitioner's Details

Doctor/Dental Practitioner *

Practice *

Address

Email address *

Telephone

Thank you

Thank you for the kind referral of your patient to Prime Childrens Dental Care. We appreciate the trust you have placed in our practice and will make it a priority to attend to your patients needs as urgently as possible. We will also keep you updated on the patient’s progress once we have accessed the situation.

Thank you again,
Prime Childrens Dental Care

Contact Us

(08) 9300 0600

Facsimile: (08) 9301 0984 (Joondalup) Facsimile: (08) 9387 7613 (Wembley) Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Joondalup

Prime Childrens Dental Care
Unit 3, 17 Davidson Terrace
Joondalup Western Australia 6027

Wembley

Prime Childrens Dental Care
151-153 Herdsman Parade (Foyer B), Level 2
Wembley Western Australia 6014

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