Away Lice Intake Form
Thank you for choosing Away Lice Removal Specialists for your lice and nit needs. Listed below is our intake form. This form can be filled out electronically at our facility. If you are receiving a in-home treatment, this form must be completed before a certified lice professional can start the treatment.
Email address *
Client Name: *
Your answer
Date of Birth *
Your answer
Age:
Your answer
Sex:
Your answer
Race:
Your answer
Blood Type:
Phone #
Your answer
Email address:
Your answer
Accompanying Adult Name
Your answer
Relationship to Child
Your answer
Place of Employment
Your answer
Is this the first occurrence?
If no, when was prior occurrence?
Your answer
How long since the onset of this occurrence?
Your answer
What methods have been used thus far?
Your answer
What was the first sign of the occurrence?
Your answer
Who found it?
Your answer
Are there siblings in the family?
What are siblings' sex and ages?
Your answer
What medical conditions does this child have that we should know about?
Your answer
Does the child have allergies?
Allergic to:
Your answer
Have you located the source of exposure?
Have they been treated
How did you hear about us:
Your answer
Means of Payment
I understand that there may be a fee for services received and agree that I am responsible for said fee. I agree to the post/ treatment guidelines and guarantee. Away Lice has my authorization to take a head shot, to be used internally at Away Lice Specialists only.
I agree to adhere to Away Lice Treatment Guarantee. It reads: The post-treatment follow-up visit appointment is scheduled and adhered to (5-7) days after the treatment. Severe cases may require a (3) day visit. Every person living with the treated individual is checked by Away Lice Removal Specialists and must be treated. The preventative guidelines are followed on an ongoing basis. The evidence of the existence of head lice is brought to Away Lice Removal Specialist for analysis. At home or self-treatments are not guaranteed.
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