Rapunzel's Lice Boutique

CONSENT FOR TREATMENT

I hereby authorize a LouseBuster Certified Operator™ to perform the LouseBuster™ Professional Head Lice Treatment on my child.

RISKS, BENEFITS AND ALTERNATIVES OF PROPOSED TREATMENT

I have discussed the anticipated benefits and risks associated with this medical treatment, and the possible consequences of not having this treatment with a LouseBuster Certified Operator™. 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 treatments for head lice infestations are not an exact science. No guarantees have been made to me by anyone as to the results of the treatment.

CLIENT CONSENT

I acknowledge that I have had the opportunity to discuss my condition, proposed treatment, concerns or questions with my LouseBuster Certified Operator™, including risks, benefits and alternative treatments. I have been given enough information, have had my questions answered, have adequate knowledge to make an informed decision and wish to proceed with the proposed treatment. By signing this waiver I irrevocably release Larada Sciences, its employees, officers, directors, contractors, shareholders and the LouseBuster Certified Operator™ listed above from any claim, action, cause of action, damage or liability associated with the services provided. I have read and understand this form and the device information provided on the other side of this document, and I voluntarily authorize and consent to the LouseBuster™ Professional Head Lice Treatment.

OUR GUARANTEE

All members of a household must be examined by Rapunzel's staff and either cleared, or treated if lice are observed. If evidence of an active lice infestation is observed within 14 days of the initial treatment we will continue to treat for free. Please bring any specimens you find with you so we may examine them.

Please check any and all conditions that apply to your child. Submit a separate form for each child that is to receive treatment.

	Is younger than 4 years old;
	cannot sense temperature or pain;
	cannot communicate physical discomfort;
	has had recent (within 6 months) radiation treatment of the head;
	has open head wounds, sores, or any visible skin/scalp condition;
	has cranial or facial implants; or
	has hair that cannot be combed through with a standard comb.

Please provide the following information about yourself and your child.

First Name of Parent or Guardian:
Last Name of Parent or Gaurdian:
First Name of Child:
Last Name of child:
Child's Birth Date:
Your Street Address 1:
Your Street Address 2:
City:
State:
Zip Code:	(5 digits)
Daytime Phone:
Evening Phone:
Email:

By clicking on the submit button, the sender is agreeing to the terms and conditons stated above. Addditionally, the sender agrees that all information submitted is accurate and complete to the best of their knowledge.

LOUSEBUSTER™ DEVICE INFORMATION

Device and Treatment Description

The LouseBuster™ is a portable, electrically powered device consisting of the main LouseBuster™ power and air supply unit, a flexible delivery hose, and a single-use applicator. During treatments, the applicator is manually positioned by a LouseBuster Certified Operator™ to systematically direct controlled heated air exiting the applicator to the entire scalp and hair roots of an individual with head lice.

Intended Use and Contraindications

The LouseBuster™ device is intended for use to kill or remove lice and lice eggs in the head hair of adults and children 4 years of age and older. It is for use on persons with untangled hair that can be combed or picked through with a standard comb. The hair must be clean, dry and free of hair treatment products. The LouseBuster™ device cannot be used to treat persons who: cannot sense temperature or pain; cannot communicate physical discomfort; have open head wounds, sores, or visible signs of skin or scalp conditions; have received radiation treatment of the head within the last 6 months; or have cranial or facial implants.

Caution

The LouseBuster™ device is very effective at killing or removing head lice and eggs. However, dead lice and dead eggs will remain in the hair after treatment. It is also possible that some lice or eggs may have been missed during the treatment. So, for cosmetic reasons, and to help assure that all lice and eggs are removed, Larada Sciences™ recommends that individual clients either receive or perform a complete comb-out with a fine-tooth louse comb after treatment. Because the device delivers heated air, there is a slight possibility of scalp burn if the device is not used according to instructions.