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Lice Rescue Intake Form
Fill out the form below to get in touch with a lice specialist. We will contact you as soon as possible.
* Indicates required question
Name
*
Your First and Last Name
Your answer
Email
Please enter the best email address
Your answer
By providing your phone number below, you agree to receive text messages from Lice Rescue regarding appointments, scheduling and other updates. Standard message and data rates may apply.
Yes, I consent to receive text messages from Lice Rescue at the mobile number provided below. I understand that I can opt-out of receiving these messages at any time by replying STOP.
Do not text me
Phone Number
*
Please enter the best contact number for you
Your answer
How would you prefer to be contacted?
Would you prefer we email, call or text you?
Email
Phone Call
Text Message.
Clear selection
Address
*
Please include Street Address, City, State and Zip Code
Your answer
What would you like to schedule?
*
Head Check(s)
Treatment(s)
School/Camp Screenings
Call with a Lice Specialist
Required
Preferred Appointment Date
*
MM
/
DD
/
YYYY
Preferred Appointment Time
Early Morning: Before 8 AM
Morning: 8 AM - 11 AM
Afternoon: 12 PM - 6 PM
Evening: 6 PM or Later
Any Time
Other:
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Number of People in Household
*
Your answer
When did the head lice symptoms start?
*
Your answer
Names and ages of Household Members
*
Please enter the names and ages of anyone who will need to be checked and/or treated.
Your answer
Hair Length
*
Short: Chin Length or Above
Medium: Chin to Shoulder Length
Long: Shoulder Blades to Mid-Back
Extra Long: Mid-Back to Waist or Longer
Required
Hair Texture
*
1
2a, 2b, 2c
3a, 3b, 3c
4a
4b
4c
Required
Please list any allergies
*
Your answer
I understand that hair must be clean and detangled upon technicians arrival.
A $15 additional fee will apply to hair that is tangled.
*
Yes
Required
I understand that full payment is due at the time of services and I have reviewed pricing.
*
Yes
Required
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