Survey

First Name:

Last Name:

Email:

Do you have Lyme Disease?

Yes No

How long have you had Lyme Disease?

Do you have any co-existing tick borne illnesses? If so, which ones?

Yes No

Were you diagnosed immediately? If not, how long did it take to be diagnosed properly?

Yes No

If the doctor prescribed antibiotics, how long was this treatment for?

Would you be willing to tell your story on our website?

Yes No

Can we contact you?

Yes No