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)

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 Perimeters

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 & extended family members are here today?

If No

Other Family Members Being Screened within 48 Hours. Enter N/A if Not Applicable

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