{"id":11439,"date":"2025-12-15T12:16:28","date_gmt":"2025-12-15T20:16:28","guid":{"rendered":"https:\/\/www.assistanceleague.org\/long-beach\/?page_id=11439"},"modified":"2025-12-15T12:50:44","modified_gmt":"2025-12-15T20:50:44","slug":"application-para-programa-orthodontico-2","status":"publish","type":"page","link":"https:\/\/www.assistanceleague.org\/long-beach\/application-para-programa-orthodontico-2\/","title":{"rendered":"Application para Programa Orthodontico"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;1\/2&#8243;][vc_column_text css=&#8221;&#8221;]<\/p>\n<h3><strong>Earl B. and Loraine H. Miller\u00a0<\/strong><br \/>\n<strong>Pavilion Orthodontico<\/strong><\/h3>\n<p>Los pacientes potenciales, de 6 a 16 a\u00f1os, pueden solicitar su ingreso al programa y deben residir en Long Beach, Lakewood o Signal Hill, o asistir a una escuela en Long Beach. La evaluaci\u00f3n de los solicitantes se realizar\u00e1 con cita previa. Los ni\u00f1os con necesidades de ortodoncia que cumplan con los requisitos ser\u00e1n aceptados en el programa despu\u00e9s de esta evaluaci\u00f3n. Durante la evaluaci\u00f3n, un m\u00e9dico examinar\u00e1 al solicitante y se revisar\u00e1n los ingresos familiares para confirmar la elegibilidad para el programa y determinar el pago mensual. Adem\u00e1s del pago mensual, se deber\u00e1 abonar una tarifa inicial \u00fanica de $120 que cubre las radiograf\u00edas y los modelos dentales.<\/p>\n<h3>Instrucctiones<\/h3>\n<p>La forma m\u00e1s sencilla de enviar esta informaci\u00f3n es completando este formulario en l\u00ednea. Una vez completado, haga clic en el bot\u00f3n Enviar.<\/p>\n<p>Sin embargo, si prefiere enviarnos la informaci\u00f3n por correo postal o fax, haga clic para descargar el <a href=\"https:\/\/www.assistanceleague.org\/long-beach\/wp-content\/uploads\/sites\/84\/2024\/06\/Refferals-for-Ortho-ENG.SPN_.pdf\">formulario en PDF<\/a> imprimible, compl\u00e9telo y env\u00edelo por correo postal o fax a la direcci\u00f3n o n\u00famero de fax que se indican a continuaci\u00f3n.<\/p>\n<p>Si tiene alguna pregunta, puede comunicarse con nosotros al (562) 425-9453 o enviarnos un correo electr\u00f3nico.<\/p>\n<h3>Direccion<\/h3>\n<p>Assistance League of Long Beach<br \/>\nA la atenci\u00f3n de: Pavilion Orthodontico Earl B. and Loraine H. Miller<br \/>\n6220 East Spring Street<br \/>\nLong Beach, CA 90815<\/p>\n<h3>Numero de Fax<\/h3>\n<p>(562) 425-9507[\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/2&#8243;]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_10' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Application para Programa Orthodontico<\/h3>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/long-beach\/wp-json\/wp\/v2\/pages\/11439' data-formid='10' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_10_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_1'>Primer Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_10_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_3'>Segundo Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_10_3' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_2'>Apellido<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_10_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_4'>Fecha de Nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_10_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_4' class='gform_hidden' value='https:\/\/www.assistanceleague.org\/long-beach\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_6'>Genero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_10_6' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='M' >M<\/option><option value='F' >F<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/li><li id=\"field_10_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Domicillio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_10_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_10_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_10_7_1' id='input_10_7_1_label' class='gform-field-label gform-field-label--type-sub '>Dirrecion<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_10_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_10_7_2' id='input_10_7_2_label' class='gform-field-label gform-field-label--type-sub '>Apt\/Unidad<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_10_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_7_3' id='input_10_7_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_7_4_container' >\n                                        <select name='input_7.4' id='input_10_7_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' selected='selected'>California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_10_7_4' id='input_10_7_4_label' class='gform-field-label gform-field-label--type-sub '>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_10_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_7_5' id='input_10_7_5_label' class='gform-field-label gform-field-label--type-sub '>Codigo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_10_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_10_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_8'>Padres o Guardian Legal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_10_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_9'>Numero de Casa<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_10_9' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_10\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_10'>Numero de trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_10_10' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_11\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_11'>Numero de Celular<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_10_11' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_12'>Refferido por<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_10_12' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_12\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_12'>Por ejemplo: vecino, familia, instagram, facebook?<\/div><\/li><li id=\"field_10_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_13'>Nombre de su Dentista General<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_10_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_14\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_14'>Fecha de ultima limpieza o chequeo<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_14' id='input_10_14' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_14_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_14_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_14' class='gform_hidden' value='https:\/\/www.assistanceleague.org\/long-beach\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_10_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_15'>Escuela<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_10_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_17\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_17'>Grado<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_10_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='K' >K<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_10_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_21'>Tiene Hermanos en el programa?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_10_21' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='Si' >Si<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_10_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_26'>Cuando estuve en el programa<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_10_26' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='Ahorra' >Ahorra<\/option><option value='En el pasado' >En el pasado<\/option><\/select><\/div><\/li><li id=\"field_10_22\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nombre de Hermano\/a<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_10_22'>\n                            \n                            <span id='input_10_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.3' id='input_10_22_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_22_3' class='gform-field-label gform-field-label--type-sub '>Primer Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.6' id='input_10_22_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_22_6' class='gform-field-label gform-field-label--type-sub '>Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_23\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_23'>Cambio de dirrecion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_10_23' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select one' >Select one<\/option><option value='Si' >Si<\/option><option value='No' 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