Help bring a smile to your community.

Complete the form below to donate 50 free toothbrushes to the Iowa school, non-profit organization or advocacy group of your choice.

All fields marked with * are required.

First and Last Name *

Your Organization Name

Your Address

Your City

Your State

Your Zip

Name of organization you would like to donate toothbrush to. *

Contact at organization (if known)

Address of organization *

Organization city *

Organization State *

Organization zip *