TickTest Order Form

TickTest Order Form
Section 1: Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone 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?

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?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What State was the Tick collected in?
...and City?
...and County?
Was the tick attached/stuck to the host?

Section 4: Payment

We accept all major credit cards.

Tick Test Service$25.00

Number of Ticks

Total $0.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Section 5: Agreement and Submit Order
Should be Empty: