Request a Lyme Disease / Tick-Borne Infections Consultation at Wave
*Second opinion requests are always welcome
Date of Birth
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Patient / Parent E-Mail
Which program are you inquiring about?
Second Opinion or Initial Evaluation
Lyme Disease/ Tick Borne Disease
Tick Bite Package
NeuroLyme Evaluation (neuropathy/neuropsych/ walking assistance)
please select one
How long have you had the symptom(s) or condition(s) about which you are consulting us?
Less than 1 month
Less than 6 months
6 months to 2 years
More than 5 years
Please briefly describe the nature of concerns.
Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, please give a general overview.
Note: a detailed overview can be discussed if you become a patient
How did you hear about us?
Current or Previous Patient
We will contact you soon.
Our office will review the information on this form to determine your scheduling needs, then contact you with appointment options. Tip: Save our local (203-442-6740) and Toll-Free # (844-468-5963) to recognize when we call
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