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DRAFT Tick Submission Form

  1. Tick Submission Form

    Danbury Seal

    Lyme Disease and other tick-borne diseases are a prevalent health concern in Connecticut. Lyme disease, left untreated for a long period of time, can become chronic. The Department of Health and Human Services offers tick testing to screen for Lyme disease and other tick-borne diseases for a fee of $5.00. 

    Instructions: Complete this form and include it with your tick specimen.

    Information on person/health department submitting tick (to whom the report will be sent): (Please identify name and email address of the person/health department official to whom the report will be sent.) 

  2. Information on person bitten by tick:
  3. Gender
  4. Leave This Blank:

  5. This field is not part of the form submission.