National Tick Removal Kit Order Form

National Tick Removal Kit Order Form

A collaborative effort of the

Greenwich Chapter, American Red Cross

and

Time for Lyme, Inc.

Affiliate of Lyme Disease Association, Inc.

Packaged in a small Red Cross bag with a belt attachment loop, the kit includes:

*Fine point tweezers with attached magnifier

*Adhesive strips *Non-latex gloves

*Alcohol prep pads *Small pencil

*Labeled zip lock bags *Gauze pads

*Tick identification and removal information card

Please send me _____ Tick Removal Kits at a cost of $10.00 per kit

Payment Method:

¨My check for $_____ is enclosed (make out to Greenwich Chapter, American Red Cross)

¨Please charge my account in the amount of $_____

___Visa ___ Master Card ___American Express

Card #____________________________

Expiration date:__________ Billing Zip Code:____________

{Please add $5.00 for shipping & Handling Cost}

__________________________________________________________

Authorized Signature

Please send my kits to:

Name:___________________________________________

Address:_________________________________________

_________________________________________

Phone number:____________________________________

Email Address:____________________________________

Any items that are not currently in stock will be ordered with a waiting period of approximately two weeks.

As soon as items are available we will follow the delivery instructions above.

Thank you for your order.

Send order form to:

Greenwich Chapter, American Red Cross

99 Indian Field Road, Greenwich, CT 06830

(203) 869-8444

For more information on Lyme disease, contact:

Lyme Disease Association, Inc.

www.LymeDiseaseAssociation.org

(888) 366-6611

November 2005