Schedule an Appointment IntakePlease fill out this form to schedule your appointment.Name:*Email Address:*Phone Number:*Street Address:*Apt / Suite / FloorCity:*State:*Zip Code:*Child's Name: (if applicable)Child's Age: (if applicable)Child's School/Camp: (if applicable)List any allergies:When did the head lice symptoms start?*Hair type (choose all which apply): above shoulder below shoulder below mid-back straight curly thin moderatly thick very thickNumber of People in Household:*DatePreferred Appointment Time:How did you hear about us?I understand that hair must be clean and detangled upon arrival. A $25 additional fee will apply to hair that is tangled.* I understand that hair must be clean and detangled upon arrival. A $25 additional fee will apply to hair that is tangled. *I understand full payment is due at the time of services:* I understand full payment is due at the time of services and I have reviews the prices. *If you are human, leave this field blank.* There is a minimum service fee of $125 per initial in-home visit which will apply towards your treatment session. (This is NOT an additional fee)** Follow up appointments have a minimum fee of $75, which will apply towards the technicians travel fee if the amount is not met with the Follow-Up Check.*** Extra thick hair and/or severe infestations may be subject to additional fees.