PALS Returning Client Quick Check-In
A Streamlined Check In Process Just For You!
Primary Phone Number on Account
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Name
*
Appointment Date
*
-
Month
-
Day
Year
Date
Who are we seeing today? (include names + screening or treatment)
*
Any changes since your last visit?
*
No changes
Yes (please explain below)
What has changed?
*
Purpose of today’s visit
*
Screening
Treatment
Follow-Up
Concern
Consent & Acknowledgment
I confirm that all previously provided information remains accurate unless noted above. I give permission for PALS Lice Treatment & Removal to perform lice screenings and/or treatments, including the use of combing, heated air devices, and topical products as needed. I understand that screenings are thorough but cannot guarantee detection of all lice or nits, and services do not guarantee against reinfestation. I agree to release and hold harmless PALS Lice Treatment & Removal, its owners, directors, employees, and contractors from any liability related to services provided.
I agree to the terms above and consent to services
*
I agree to the terms above and consent to services
Signature
*
Check In
Should be Empty: