Lyme Testing Note: All info must be filled out properly or the form will not go through. Please fill out the following form to request Lyme disease testing: Your Name (required) Your Email (required) Phone Number (required) Have you ever been bitten by a tick? —Please Select—YesNoI don't remember How old are you? (required) What city and state are you located in (required)? Who were you referred by (required)? How can I help you (required)? Please list your symptoms: (required) How much money are you requesting for Lyme disease testing? What is the name, address and phone number of the Lyme literate physician that you will be seeing? Additional Comments:
