Refer a Patient to Bye-Bye Pesky Lice
Use this form to refer a family for professional, in-home lice screening and treatment. Our team will contact them promptly to provide assistance.
Referred By (Dr. Name or Clinic Name)
*
Parent or Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
City & ZIP Code
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any Notes or Special Considerations?
Submit Form
Should be Empty: