Section 1: Personal Information
Date of Submission (dd/mm/year):
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Organization Name
First Name
*
Last Name
*
Email
*
Phone (### ### ####)
Street Address
*
City / Town
*
Province
*
Postal Code
*
Section 2: Tick Information
Number of ticks being submitted:
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If the tick was attached to an animal/pet, please specify the animal:
Age of affected individual:
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Where do you believe the tick was first contacted (i.e. name of forest, park, town, etc.)?
What was the individual doing when they contacted the tick (i.e. hiking, gardening, etc.)?
What was the individual doing when they contacted the tick (i.e. hiking, gardening, etc.)?
Do you consent to collected information being used to further the study of tick-borne diseases in Canada?
*
Yes, I agree to this aggregate information being used to further research into tick-borne diseases in Canada.
No, do not use my aggreate information for tick-borne research.
IMPORTANT: After you select "Submit", you will receive an email confirming the details of your submission. Please print this email and include the physical copy when you mail your tick(s) to Geneticks.
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Submit
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