Redbridge e-forms Pest treatment record Customer detailsReference number(Required)First name(Required)Last name(Required) Do they live in Redbridge(Required) Yes No Enter postcode(Required)Find addressSelected address Address(Required) 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 Customer contact detailsEmail Telephone number Appointment detailsFirst appointment date(Required) Day Month Year Time (24 hrs)(Required) Hours : Minutes Operative detailsOperative first name(Required)Operative last name(Required)Operative email address(Required) Risk assessmentPresence of pest confirmed(Required) Yes No Please specify the pestsRisk assessed & acceptable for treatment(Required) Yes No Risk assessmentPresence of animals(Required) Yes No Please specify the animalsRisk assessed & acceptable for non-target animals/pets(Required) Yes No Risk assessmentPresence of children(Required) Yes No Please specify about childrenRisk assessed & acceptable for children(Required) Yes No Risk assessmentOther(Required) Yes No Please specify if otherRisk assessed & acceptable(Required) Yes No Additional Information Pest & treatment detailsPremises type(Required) Domestic Commercial Pest(Required) Rats Mice Cockroaches Bed bugs Black ants Pharaoh ants Wasps Other If other pests, please specify(Required) Pest & treatment detailsRodenticides 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(Required)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(Required)Was occupier advised and given safety information(Required) Yes No Treatment detailsCan you proceed with the treatment?(Required) 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 specifyProofing and Housekeeping detailsPlease upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 50 MB. Details of 1st visitFirst appointment date Day Month Year Initial visit – areas treated/number of baiting points(Required)Operative(Required) Details of 1st visitProofing done(Required) Yes No Please upload any photos here. You can upload multiple photos Drop files here or Select files Max. file size: 50 MB. 2nd visit requested(Required) Yes No Details of 2nd visitSecond appointment date Day Month Year 2nd visit(Required)Operative(Required) Details of 2nd visitProofing done(Required) Yes No Pesticide removed Yes No Reason for not removing pesticide(Required) 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: 50 MB. 3rd visit requested(Required) Yes No Details of 3rd visitThird appointment date Day Month Year 3rd visit(Required)Operative(Required) Details of 3rd visitProofing & housekeeping advice followed(Required) Yes No Pesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 4th visit requested(Required) Yes No Details of 4th visitForth appointment date Day Month Year 4th visit(Required)Operative(Required) Details of 4th visitProofing & housekeeping advice followed(Required) Yes No Pesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 5th visit requested(Required) Yes No Details of 5th visitFifth appointment date Day Month Year 5th visit(Required)Operative(Required) Details of 5th visitProofing & housekeeping advice followed(Required) Yes No Pesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 6th visit requested(Required) Yes No Details of 6th visitSixth appointment date Day Month Year 6th visit(Required)Operative(Required) Details of 6th visitProofing & housekeeping advice followed(Required) Yes No Pesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 7th visit requested(Required) Yes No Details of 7th visitSeventh appointment date Day Month Year 7th visit(Required)Operative(Required) Details of 7th visitProofing & housekeeping advice followed(Required) Yes No Pesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 8th visit requested(Required) Yes No Details of 8th visitEigth appointment date Day Month Year 8th visit(Required)Operative(Required) Details of 8th visitProofing & housekeeping advice followed(Required) Yes No Pesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 9th visit requested(Required) Yes No Details of 9th visitNinth appointment date Day Month Year 9th visit(Required)Operative(Required) Details of 9th visitPesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 10th visit requested(Required) Yes No Details of 10th visitTenth appointment date Day Month Year 10th visit(Required)Operative(Required) Details of 10th visitPesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 11th visit requested(Required) Yes No Details of 11th visitEleventh appointment date Day Month Year 11th visit(Required)Operative(Required) Details of 11th visitPesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. 12th visit requested(Required) Yes No Details of 12th visitTwelveth appointment date Day Month Year 12th visit(Required)Operative(Required) Details of 12th visitPesticide removed(Required) Yes No Reason for not removing pesticide(Required) 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: 50 MB. Feedback Please complete the Customer feedback form after you submit this form.
