TICK TEST REQUEST FORM

TO SEND A TICK:

• Place ticks (up to 20) in a small tube or plastic baggy with a small piece of moist cotton.
• Place container in a sealed plastic bag.
• Print this form.
• Fill out all sections of this form.
• Place form, check and sealed plastic bag in padded envelope or box.
• Send to IGeneX, Inc. and mark front of envelope or box with "TT."

For Multiple Ticks: Up to 20 ticks will be tested together at one time, unless indicated otherwise.
If ticks are tested separately, the charge will be per tick.

Please test my ticks separately. [___] Yes

Please test the tick by PCR for:

[___]	Test 140	Lyme Disease (Borrelia burgdorferi)					$60.00
[___]	Test 141	Babesiosis (Babesia)					$60.00
[___]	Test 675	WA-1 (Northern California)					$60.00
[___]	Test 148	Ehrlichiosis (Ehrlichia)					$60.00
[___]	Test 290	Bartonella henselae					$60.00
Name and Address of Sender:If you would like completed results faxed or called, please indicate below. Otherwise, results will be mailed by USPS.
____________________________							[___]  Please fax my results to:
____________________________							(          ) _________  __________
____________________________
Phone:							[___]  Please call me with my results at:
(          ) _________  __________							(          ) _________  __________
[___]		Check enclosed payable to IGeneX, Inc.
[___]		Please charge my credit card for the above tests:
[___]  VISA		[___]  Mastercard		[___]  Discover
Card Number: ______________________________________________________
Expiration Date: ____________________________________________________
Signature: _________________________________________________________

IGeneX, Inc.
795 San Antonio Rd., Palo Alto, CA USA 94303
Tel. 650.424.1191 / 800.832.3200 Fax. 650.424.1196