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