Orthodontic Referral Form

Earl B. and Loraine H. Miller Foundation
Orthodontic Center

New Patients are seen at screenings nine times per year (not in June or December).  New patients must be between the ages of 11-16, qualify as "low income", and live in Long Beach, Lakewood, or Signal Hill, or attend a Long Beach Unified School District (LBUSD) school. Start-up fee is $100. Monthly fees range from $55-75 per month, once braces are applied.

Instructions

The easiest way to submit this information is by completing this Online Form. After completing it, click "Send Email to Ortho Center" button.

However, if you prefer to mail or fax the information to us, click to download the printable PDF form, fill it in, then mail or fax it to us at the address or fax number below.

If you have any questions, you can contact us at (562) 985-1175 or send an email message to us.

Mailing Address

Assistance League of Long Beach
Attn:  Earl B. and Loraine H. Miller Foundation Orthodontic Center
6220 East Spring Street
Long Beach, CA 90815

Fax Number

(562) 985-1175

Online Referral Form

*
*
*
*
*
*
*
*
*
*
*
*
*
*