Prosthodontics Specialist Dental Centre

    Dandenong Implant Centre

    Dr. Mohammed Ibrahim

    Registered Prosthodontist

    Dr. Jaafar Abduo

    Registered Prosthodontist

    Referral for Prosthodontic Management

    Please note: items marked * indicate mandatory fields.

    Clinic Name:*
    Dentist Name*:
    Address*:
    Suburb*:
    State*:
    Postcode*:
    Phone*:
    Patient Name*:
    Contact Numbers*:
    DOB*:
    Date of Referral*:

    Please advise patients Dr Ibrahim’s rooms will contact them upon receiving the referral.

    I would like to refer the above patient to you for specialist care of (Please Tick):

    🗹 Fixed Prosthodontic (Veneers, Crown and Bridge Construction)
    🗹 Full Mouth Rehabilitation
    🗹 Implantology
    🗹 Removable Dentures (Partial and Full)
    🗹 Temporo - Mandibular Disorders
    🗹 Treatment Assessment
    🗹 Other
    Other relevant dental or medical information:
    Other relevant dental or medical infoormation: