Head Lice Removal Service Agreement
This document is a consent form for professional head lice removal and treatment. It authorizes a business to perform the treatment on a client, releases the business from liability, and includes a guarantee for follow-up treatment if head lice are observed within 14 days.
Head Lice: Consent for Treatment
[name of party 1] (hereafter “Party 1”) hereby authorizes the professional head lice removal and treatment of [name of client 1] (hereafter “Client 1”). [add additional clients as needed, such as in the case of family with multiple affected children]
The [treatment type or procedure] protocol involves [protocol]. Head lice treatment is not an exact science. Any treatment involves some risks and hazards, and Party 1 is responsible for considering alternatives and weighing the benefits for their family. By signing below, Party 1 agrees to hereby release [name of business] (hereafter “Business”) and its employees from any claims, damages, or liability related to the treatment. Moreover, by signing, Party 1 also acknowledges that Client(s) do not have any diseases, conditions, or other issues that would make treatment inappropriate. These include, but are not limited to, [inability to communicate pain, younger than xx years, sores on the scalp, recent radiation treatment, etc.]
OUR GUARANTEE
If all members of a household have been treated and cleared by Business, and head lice are observed within 14 days, we will continue to treat at no additional charge.
In witness to their agreement to the terms of this contract, the parties affix their signatures below:
____________________________________ _________________________________
[name of party 1] [business representative]
[signature] [signature 1]
[date] [date 1]
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