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Albuquerque Patient Consent Form
I hereby authorize a Certified AirAlle Operator to perform the AirAlle Professional Head Lice treatment on any and all household members listed above.
Risks, Benefits and Alternatives of proposed treatment:
The Certified AirAlle Operator has discussed with me the anticipated benefits and risks associated with this medical treatment, and the possible consequences of not having this treatment. I understand that any medical treatment can involve some risks and hazards. I have been made aware of the risks associated with this particular treatment. This authorization is given with the understanding that treatment for head lice infestations are not an exact science.
Client Consent:
I acknowledge that I have had the opportunity to discuss my condition, proposed treatment, concerns or questions
I understand that in order to receive the twenty-one day guarantee; all members of the household must be checked and treated for head lice within 36 hours. The guarantee is void in the case that any family members not checked or refuses treatment. The 21 day guarantee only applies for the full service treatment and cannot be applied to any other services provided. The client is responsible for cleaning their home and car to prevent re-infestation. The client will be provided with these instructions and agrees to follow them or the 21 day guarantee will become void. In the unlikely instance of technician malfunction, we will retreat the client free of charge the refunds will not be given.
That AirAlle treatment is contraindicated for anyone under the age of four (4,) individuals with any impairment that causes them to be nonverbal, individuals who have recently received radiation treatment to the head, individuals with metal plates or foreign objects in their head, and individuals with any open wounds or sores to the head. The client is required to notify technician if of any of these contraindications are present.
By signing below, I acknowledge that a Certified AirAlle Operator has discussed with me the benefits of having the treatment and the potential consequences of not having the treatment. I am aware of the potential risks associated with all the treatment options available, including treatment with the AirAlle device. I also understand that treatment of head lice infestation is not an exact science.
By signing this waiver, I irrevocably release Larada Sciences, Lice Clinics of America, and their owners, employees, officers, directors, contractors, shareholders, and the Certified AirAlle operator from any claim, action, cause of action, damage, and/or liability associated with the service provided.
First and Last Name
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