RADIATION AND PUBLIC HEALTH

Mission Statement – to conduct research on health hazards of nuclear power, and educate citizens and officials on results

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Tooth donation form

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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?):

______________________________________________________________________________________

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