BodyScience TickBorne Intake Form

BodyScience TickBorne Intake Form

Please complete the information below, it is needed for us to fill up the lab test request, and to follow up with you once the results are back. For question, please call us at 305-901-5888
Name*

First NameLast Name
Birthday*

MonthDayYear
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date

MonthDayYear
Date
I'm Interested on this test*

TickBorne 2.0 panel - $1050 (TEST ONLY)TickBorne 2.0 panel - $1200 (Test + group explanation)TickBorne 2.0 panel - $1300 (Test + one-on-one explanation)
Tickborne Diseases Test

Tickborne diseases are rising throughout the US from a variety of ticks, which carry and pass on different microorganisms to humans and animals. Tickborne diseases have more than doubled in 13 years and represent 77% of all vector-borne disease reports. Lyme disease accounts for 82% of all cases.
Disclaimer*

Please note that Amy Jaramillo will be leading the call. She is not a medical doctor, and the information provided is for educational purposes only, not as medical advice. The information provided here should not replace or delay professional medical consultation. If you have concerns about your health or symptoms, please seek the advice of a licensed medical practitioner. Please check the box to agree before proceeding with the purchase of the test plus explanationI'm purchasing TEST ONLY
Should be Empty: