Forms home Pest treatment record "*" indicates required fields 1Customer details2Appointment details3Risk assessment4Pest & treatment details5Treatment details6Details of 1st visit7Details of 2nd visit8Details of 3rd visit9Details of 4th visit Service Request Date: DD slash MM slash YYYY Reference number* Customer detailsFirst name* Last name* Email* Do they live in Redbridge* Yes No Enter Postcode*Find addressSelected address Address* Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Appointment detailsTime (24 hrs)* Operative DetailsOperative First name* Operative Last name* Operative email address* Risk assessmentPresence of pest confirmed* Yes No Please specify the pestsRisk assessed & acceptable for treatment* Yes No Presence of animals* Yes No Please specify the animalsRisk assessed & acceptable for non-target animals/pets* Yes No Presence of children* Yes No Please specify about childrenRisk assessed & acceptable for children* Yes No Other* Yes No Please specify if otherRisk assessed & acceptable* Yes No Additional Information Pest & treatment detailsPremises type* Domestic Commercial Pest* Rats Mice Cockroaches Bed bugs Black ants Pharaoh ants Wasps Other If other pests, please specify* Rodenticides Raccumin Foam Sakarat D Whole Wheat Contrac Super Blox Solo Super Blox Rodilon Wheat Tech. Rat / mouse bait Ratimor brodifacoum block Ratimor difenacoum block Ratimor bromadiolone soft block Rodolin difethialone soft block Other If other Rodenticides, please specify* Insecticides Cimetrol Super EW Biopren 6 EC Effect Ultimum Pro Effect Microtech CS Pro K-Othrine Partix Cytrol Forte WP Maxforce Platin Gel Advion Cockroach Gel Bayer Flying Insect Killer Biopren BMS Advion Ant Gel Maxforce Quantum Gel Ficam D Vulcan PS DP. Other If other Insecticides, please specify* Was occupier advised and given safety information* Yes No Treatment detailsCan you proceed with the treatment?* Yes No Please specify the reasons for not proceeding with the treatment No infestation present Operator safety Housekeeping/Husbandry Different species found Pre spray preparation not of an acceptable standard No one at present at the time of appointment - No Access Card left Treatment area not prepared as required – Customer pretreatment advice given again. Tenant/Occupier refused access. Other If other reason, please specify Proofing and Housekeeping details Please upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 10 MB. Details of 1st visitInitial visit – areas treated/number of baiting points*Operative* Proofing done* Yes No Please upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 10 MB. 2nd visit requested Yes No Details of 2nd visit2nd visit*Operative* Proofing done* Yes No Pesticide removed Yes No Reason for not removing pesticide* Refusal by customer No bait to take away Further visit required Please upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 10 MB. 3rd visit requested* Yes No Details of 3rd visit3rd visit*Operative* Proofing & housekeeping advice followed* Yes No Pesticide removed* Yes No Reason for not removing pesticide* Refusal by customer No bait to take away Further visit required Please upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 10 MB. 4th visit requested* Yes No Details of 4th visit4th visit*Operative* Proofing & housekeeping advice followed* Yes No Pesticide removed* Yes No Reason for not removing pesticide* Refusal by customer No bait to take away Further visit required Please upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 10 MB. Please complete the Customer feedback form after you submit this form.
