Skip to form

City of Stamford Health Laboratory

Stamford Government Center 888 Washington Boulevard 8th Floor Stamford, CT 06901

(203) 977-4378

SeamlessDocs

Form may look distorted however the printouts will be fine.

Electronic Submission of this form is not accepted.

Please print completed form and bring to the Health Laboratory at 888 Washington Blvd.

Thank you.
By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
x

Additional Signatures Required