CLIENT(S) INFORMATION

I understand that the 30-day guarantee is only valid if I have if ALL family members living within the household of those treated are screened, cleared (or treated) by Lice Clinics of America. This must include secondary households or split household members. Refer to the clinics policy page for additional information. Please initial below.

Acknowledgement of guarantee policy above

By initialing below, I am choosing NOT to have ALL household members screened, cleared and/or treated, and therefore waive the treatment guarantee.
To be signed only if opting out of the guarantee


CLIENT CONSENT FOR TREATMENT


FOR THOSE RECEIVING AN AIRALLÉ® TREATMENT

The AirAllé® is an FDA-cleared medical device to treat head lice. It is very effective at killing both live lice and their eggs. After treatment with the AirAllé device, Larada Sciences (the manufacturer of the AirAllé®) recommends you receive or perform a complete comb-out. Because the AirAllé® device distributes heated air onto the scalp, if the instructions for use are not followed carefully, there is a very slight possibility that the scalp could be burned. If the heated air becomes uncomfortable on your scalp during the treatment, you must tell the Certified AirAllé Operator immediately.

By signing below, I acknowledge these statements are true for me (or for the child for whom I am signing):

Able to sense temperature and pain
Able to communicate physical discomfort
Have not had radiation treatment of the head in the last six months
Do not have any open head wounds, sores, or a visible skin/scalp condition
Do not have cranial or facial implants
Do not have hair extensions

Acknowledgment of the above statements

I understand that the AirAllé® device has not been cleared by the FDA for use on children under the age of 4 years old. By signing below, I am consenting to the treatment for a child under the age of 4.

Consent to treat a child under 4 (if applicable)


FOR THOSE RECEIVING A TOPICAL PRODUCT APPLICATION

A Lice Clinics of America™ topical product will be applied during treatment. I am aware that some of the treatment products contain soap and fragrance.

By initialing below, I acknowledge that I have no allergies or sensitivities to soap or fragrance.


FOR THOSE RECEVING A COMB-OUT SERVICE

I acknowledge that a comb-out service can require additional home care and a follow up visit.

We recommend that all members of the household where there is a positive case receive a topical product application as a precautionary measure. Please confirm this option was offered.

Would you like to extend your 30-day guarantee? We can offer year-round lice protection with our Protection Plan. We have options for one or all of your family members. Your technician can give you all the details.

This document is for internal use only. It contains information about our clients. Please do not reference it outside of the company.