Registration Form

Registration Form
Parent/Guardian/Self Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Zip Code
How many people are being seen today?
Person 1 Name

First NameLast Name
Person 1 Age
Person 1 School / Daycare / Camp
Required when applicable
Person 2 Name

First NameLast Name
Person 2 School / Daycare / Camp
Required when applicable
Person 2 Age
Person 3 Name

First NameLast Name
Person 3 School / Daycare / Camp
Required when applicable
Person 3 Age
Person 4 Name

First NameLast Name
Person 4 School / Daycare / Camp
Required when applicable
Person 4 Age
Person 5 Name

First NameLast Name
Person 5 School / Daycare / Camp
Required when applicable
Person 5 Age
Person 6 Name

First NameLast Name
Person 6 School / Daycare / Camp
Required when applicable
Person 6 Age
Person 7 Name

First NameLast Name
Person 7 School / Daycare / Camp
Required when applicable
Person 7 Age
Person 8 Name

First NameLast Name
Person 8 School / Daycare / Camp
Required when applicable
Person 8 Age
Person 9 Name

First NameLast Name
Person 9 School / Daycare / Camp
Required when applicable
Person 9 Age
Person 10 Name

First NameLast Name
Person 10 School / Daycare / Camp
Required when applicable
Person 10 Age
How many people are in the family/household?
Does the child or any person being seen regularly stay in more than one household?
Which PALS location are you visiting today?
Have you been a client of ours before?
What name were you previously registered under?

First NameLast Name
Approximately when were you last seen by PALS?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which PALS location did you previously visit?
Have you been treated or seen by another facility in the last 30 days?
When were you seen?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where were you seen?
Was treatment provided?
Does anyone being seen have a sensory sensitivity, behavioral concern, medical consideration, or other need we should know about before the appointment?
Please share anything that would help PALS provide a comfortable and safe appointment.
Does anyone being seen currently have hair extensions, locs/dreadlocks, significant matting or tangling, or another hair condition we should know about?
Please tell us which person and what hair condition applies.
How did you hear about us?
Please provide more details.
Our screenings are thorough, but they do not carry a guarantee. We stop the screening once evidence of head lice is identified, then show you the evidence and explain your treatment options. If lice is found, we’ll review your options with you. There is no obligation to begin treatment.

If helpful, we may recommend our optional Peace of Mind oil-based screening, which is more comprehensive and may be especially useful for extensive or thick hair, though it also does not carry a guarantee.

PALS may decline or discontinue service when needed for safety, when a service cannot be completed appropriately, for noncompliance with service requirements, or when circumstances fall outside the scope of our services. When appropriate, we may offer alternative guidance.

Service plans, pricing, and policies may change, and proprietary PALS materials may not be photographed or reproduced without authorization.
PALS welcomes children with sensory sensitivities or behavioral challenges and will do its best to provide a positive experience. In some cases, treatment may not be able to be completed. Matted or significantly tangled hair may require additional time and fees. Please contact PALS before your appointment with any concerns.
🎉 Fun Paks Are On Us! Every child receiving treatment gets a complimentary PALS Fun Pak. Additional Fun Paks for siblings or friends are available for $3.99.
Print Name (Parent or Guardian) Must Match ID
If yes, what name did you register under if different than the one listed?
Signature
If yes, what company?
- Should be Empty: