Intake Form

Full Name*

First NameLast Name

Age*

Date

Gender:*

MaleFemaleOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail

Doctor's Name:

School:

(**Lice Clinics of America is HIPAA-compliant and never gives out patient information- all information requested in regards to doctors and schooling is used to reach out and offer our services to places that have an influx of potential patients.)

How did you hear about us?

Please list all family members names and ages and which ones are present today*

Are all members of your household here today?*

YesNo

The signature guarantee is a 30-day guarantee that allows patients who qualify to get retreated for free, if necessary. If patients come in to get a new screening after their treatment, they will have to pay the full price of screening if they are found to not have an active infestation.*

I understand that I do NOT qualify for the signature guarantee today.

The signature guarantee is a 30-day guarantee that allows patients who qualify to get retreated for free, if necessary. If patients come in to get a new screening after their treatment, they will have to pay the full price of screening if they are found to not have an active infestation.*

I understand that I qualify for the guarantee and accept the conditions that apply to it.

Please sign below to acknowledge you understand our guarantee policy:*

Symptoms (Check all that apply):

Previous Treatment? (In regards to this current infestation)

Patient Information: