| Appointment Request |
| Customer Information |
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Name(*) |
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Address |
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City |
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Postal Code |
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Home Phone |
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Work Phone |
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Email Address (*) |
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Cell Phone |
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We should contact you FIRST at : |
Home phone Work phone
Cellphone Email |
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Have you been in Car Medics before? |
Yes No |
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If yes, have we seen this vehicle before? |
Yes No |
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If not, how did you hear about us? |
Web site
Yellow Pages
Advertising, Which Ad?
Customer Referral, From?
Svendsen Bros. Automotive
Other |
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Appointments |
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Year |
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Make |
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Model |
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What date would you like to bring your
vehicle in (or what date is your
appointment already set for): |
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Second Choice |
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What time would you like to schedule
your appointment for or when are you
dropping it off to us? |
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You would like to: |
Wait while your vehicle is serviced
Leave it with us |
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Will need a ride to your destination? |
NO
YES, Going to:
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Will you require a return ride when
your vehicle is ready? |
NO
YES, from where? |
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When will you need your vehicle back? |
Date Time |
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Service Request (s) |
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Please provide as many details as
possible on the services you selected: |
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Inspections |
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Brake Inspection
Provincial Safety Inspection
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Inspect Vehicle for Purchase
Inspect Vehicle for Trip to
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Diagnostic Inspections |
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Engine or Service Light Diagnosis
Diagnose Vibration
Diagnose Noise (s)
Diagnose Braking Problems
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Diagnose Engine Running or Starting Problem
Diagnose Alignment Problem - Vehicle Pulls
Diagnose Fluid Leak (s)
Diagnose Air Conditioning / Cabin Heating /
Engine Overheating Problem (s) |
