Patient Referral — Plymouth Orthodontics

PLYM

UTH

Orthodontics
Ourania Vitsas, DMD

Thank you for referring a patient to Plymouth Orthodontics. Please complete the form below and we'll reach out to your patient within one business day to schedule their consultation. We'll also send you a confirmation of receipt.

Referring office

Doctor's name *

Practice name

Doctor's email *

Practice phone

Best way to reach you

Email Phone Either is fine

Patient information

Patient name *

Date of birth

Patient phone *

Patient email (optional)

Parent / guardian (if minor)

Referral date

Dental history

Date of last cleaning and checkup

Panoramic radiograph is available

Restorative work needed

Additional attachments (optional)

Other files (x-rays, photos, charts — up to 10 MB each)

Remarks

Notes for Dr. Vitsas and the Plymouth Orthodontics team

By submitting, you confirm the patient has consented to this referral. We'll email you confirmation once it's received.

Please call 508-815-1695 or email info@plymouth-orthodontics.com to schedule your appointment. Thank you for your referral and support.

Ourania Vitsas, DMD