Acknowledgement of Services

Clients Name: __________________________________________ Date: ______________________
Start Time: ____:____ AM/PM Initial: ______ Finish Time: ____:____ AM/PM Initial: ________

Please complete form in its entirety. Do not leave any box unchecked. If you have questions please speak to your technician before initialing the Service Form.


_______ Initial I acknowledge that No Nits Lice removal Services will come to my residence and assess, and treat my family members for lice, nits and louses. The technician will provide the form “Family Follow up Plan” depending on severity. I understand the process and will contact the technician if I have any questions or concerns.

_______ Initial I acknowledge that it is normal for some nits may be visible. I understand that for total eradication, I must abide by the follow-up plan and will give the plan 3 weeks to fully work. I will apply olive oil to the hair every day for 3 days and then on days 9 and 16. (5 times). I will apply the oil on days 6 and 12 if my tech has suggested that I do so because of a very severe infestation. Please note that if your tech has left you with oil in your hair, you must supplement it just prior to bedtime so that it is saturated.

_______ Initial I acknowledge that it is normal for some nits to show up in the hair over the next couple of weeks.* If I see a live bug(s) in the next day or so, that indicates that I did not adequately saturate the hair and that I must apply more olive oil at night and comb through so that there are no dry spots. If I have concerns, I will call customer service who may request pictures. If I insist that a technician return before the follow-up plan is completed, I agree to pay a reduced fee of $150/$99 for the recheck. I understand that I will not be refunded if I go to another company before giving my “Not Nits” treatment and follow up the full time to be effective.

_______ Initial My technician has shown me what nits look like and has explained the difference among nits, debris, and DEC plugs. (Only if applicable) My technician has advised me that we had a very severe infestation and that I may see an above average number of nits and or bugs post-treatment.