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2. Tick Submission Form

   

   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.) 

4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
17. Information on person bitten by tick:
19. Name (if different from above):
21. Address (if different from above):
23. Age:
24. Gender

    1. M
    2. F
26. Date tick was removed?:
    Date tick was removed?:
27. Part of body where tick was found:
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field