| Tooth Donation Form Please fill out the following form and send it with your baby teeth
to: Radiation and Public Health,
PO Box 60, |
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| Mother: | _______________________________________________________________________ First Last |
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| Phone: | ________________________ Area Code Phone Number |
Email: ______________________________________ |
| Address: | _______________________________________________________________________ Street _______________________________________________________________________ City State County Zip |
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| Child's Name: | _______________________________________________________________________ First Last |
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| Birth Date: | ________________________ Month Day Year |
Birthweight: ________________________________ Pounds Ounces |
| Sex: | Female ____ Male ____ | |
| Residence when mother was pregnant: | ||
| _______________________________________________________________________ City State County Zip |
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| Residence where child was born: | ||
| _______________________________________________________________________ City State County Zip |
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| Residence during first year of life: | ||
| _______________________________________________________________________ City State County Zip |
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| Mother's Date of Birth: | ________________________ Month Day Year |
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| Mother's place of birth: | ||
| _______________________________________________________________________ City State County Zip |
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| Does the child have a long-term health problem? Yes ____ No ____ | ||
| If the answer is yes, please explain (all answers will be
kept confidential) |
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| Water source: (from well, municipal water, bottled water,
or?): ______________________________________________________________________________________ |
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