Consent Form

(to be filled out by the client or legal representative)

 

I hereby authorize a certified AirAllé® Operator to perform a professional head lice treatment (scalp pediculosis).

By my signature, I attest that the certified AirAllé® Operator has informed me of the benefits of the treatment as well as the potential consequences of not receiving the treatment. I am aware of the potential risks associated with the proposed treatment options, as well as those related to the AirAllé® procedure. The characteristics of a head lice infestation, such as resistance developed to other treatments, infestation rate, type of infested hair, etc., can vary from person to person. I understand that the outcome of the treatment is not an exact science. A detailed information sheet about the AirAllé® treatment has been shown to me by NOPOU. I have taken the time to carefully review this document and have received answers to all of my questions. I have all the necessary information to make an informed decision regarding the treatment that is right for me.

By my signature, I release all employees and representatives of NOPOU and Larada Sciences Inc. from any claims, causes of action, damages, and/or liabilities related to the service provided.

AIRALLÉ® TREATMENT

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  • Est âgée de 4 ans ou plus
  • Est capable de ressentir la température et la douleur
  • Est capable d’exprimer ou de communiquer tout inconfort physique
  • N'a pas eu de traitement par radiation à la tête au cours des six derniers mois.

  • N'a pas de blessure ouverte à la tête, d’écorchures ou tout autre signe visible de pathologie de la peau ou du cuir chevelu.
  • N'a pas d'implants crâniens ou faciaux.
  • N'a pas de cheveux qui ne peuvent être peignés avec un peigne standard (inclus les dreadlocks et les extensions)

Informations du tuteur

Personne(s) à traiter

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