Tooth Donation Form

Please fill out the following form and send it with your baby teeth to: Radiation and Public Health, P.O. Box 1260, Ocean City NJ 08226.

Thanks for helping!

Mother: _______________________________________________________________________
First                                                  Last
Phone: ________________________
Area Code     Phone Number
Email: ______________________________________
Address: _______________________________________________________________________
Street       

_______________________________________________________________________
City                        State               County                       Zip                                  
Child's Name: _______________________________________________________________________
First                                                  Last
Birth Date: ________________________
Month      Day       Year
Birthweight: ________________________________
                    Pounds               Ounces
Sex: Female ____ Male ____  
Residence when mother was pregnant:
  _______________________________________________________________________
City                        State               County                       Zip           
Residence where child was born:
  _______________________________________________________________________
City                        State               County                       Zip    
Residence during first year of life:
  _______________________________________________________________________
City                        State               County                       Zip    
Mother's Date of Birth: ________________________
Month      Day       Year
Mother's place of birth:
  _______________________________________________________________________
City                        State               County                       Zip    
Does the child have a long-term health problem? Yes ____ No ____

If the answer is yes, please explain (all answers will be kept confidential)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Water source: (from well, municipal water, bottled water, or?):

______________________________________________________________________________________