TickTest Order Form

TickTest Order Form
Section 1: Contact Information
Name *

First Name Last Name
Phone Number *

- Area Code Phone Number
E-mail *
How did you hear about TickTest? *

Section 2: Test Information

The price of our service is $40.00 per tick. All ticks will be tested for Borrelia burgdorferi, the causative agent of Lyme Disease.

If you are interested in having the tick tested for a different pathogen, please contact us at contact@immunotechnologies.com.

You have the option of sending us more than 1 tick, as long as the tick comes from the same host. If the ticks were found on different people, animals, places, etc, please generate a new order for each tick. A maximum of 5 ticks can be sent to us in one order.

Please note, if you place an order for 1 tick, and send us multiple ticks in the mail, only 1 of those ticks, chosen at random, will be tested.
Do you plan to send us more than 1 tick? *

Yes No

Section 3: Tick Information
What host was the tick obtained from? *
Remeber, the host is the person or place where the tick was collected off of.
What day was the tick collected from the host? *

- Month - Day Year
Date
What State was the Tick collected in? *
...and City? *
...and County? *
Was the tick attached/stuck to the host? *

Yes No

Section 4: Payment

We accept all major credit cards. *

Tick Test Service $ 50.00

Number of Ticks

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Section 5: Agreement and Submit Order
Should be Empty:

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