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Tick Tag Go Specimen Form
Please complete every field before mailing or dropping off a form. You will receive a receipt of your responses at the email address you provide. Please print it and include it with your specimen.
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* Indicates required question
Email
*
Your email
Your first and last name:
*
Your answer
Your phone number (if this is preferred contact method):
Your answer
Date tick was observed / collected (Month, day, year)
*
MM
/
DD
/
YYYY
Location that tick was collected. Please provide a street address, city, zip code so that we can map location.
*
Your answer
Tick found on (where was the tick collected?). Select one:
*
Person
Animal
Free in the environment
Other:
Was the tick attached to the skin?
*
Yes
No
Maybe
Unsure
Name the location on the body where the tick was attached.
Your answer
Please add any other comments here:
Your answer
A copy of your responses will be emailed to the address you provided.
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