PALS Intake and Consent Form

DateTime

Name

First NameLast Name

A certified Lice Technician has explained the various treatment plans in detail so that I may select the plan that is best for my family

I have Chosen the following Plan (s)

Policy Update: Complimentary screenings and promotional benefits are specific to the service purchased, have no cash value, are not interchangeable, and cannot be combined, transferred, substituted, or stacked with benefits from another service.

Peace of Mind Comprehensive Screening is not a lice treatment and includes no treatment guarantee. It includes one complimentary follow-up screening within 30 days, available on Saturdays only and by appointment.

I acknowledge the Peace of Mind Comprehensive Screening terms

Was lice or evidence of an active infestation found?

I understand the plans are prorated and billed in 15 minute increments per person. Additionally I have been given a pamphlet and/or had explained in detail what needs to be done with my home.

Guarantee Parameters

I understand that all household members living under one roof must be checked & cleared (or treated if necessary) within 24/48 hours to honor guaranteed services. Families with blended households must have all members & caregivers in both households checked & cleared or treated within 24/48 hours.

If the Head Start Plan was selected I understand that a guarantee does not apply.

I have read and understand the Guarantee Perimeters

Are all household members and applicable extended/blended-household members here today?

Why is a household member not being screened today?

Who is the screening waiver for?

Please explain.

Other Family Members Being Screened within 48 Hours

The PALS 30-45 day guarantee has been explained in detail. I understand this does not apply to the Head Start Plan. If all parameters are met and I find a live louse anytime within 30-45 days, I must save the live louse to be retreated for free. If not saved, a screening fee will apply. Services are guaranteed only if I return to PALS. If I use another service, all payments are irrevocable, non-refundable, and non-creditable.

All of my questions have been answered and I wish to proceed with PALS treatment. By signing this form, I irrevocably release Let’s Be P.A.L.S., LLC, its employees, contractors, officers, directors, and shareholders from any claim, action, cause of action, damage, or liability associated with services provided. I authorize a certified PALS technician to perform a professional head lice removal treatment on any/all individuals in my party.

Let’s Be PALS Intake & Consent Form