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Drop Off Form
Drop Off Form
Early Bird & Night Owl
Pre-Service Check-In Envelope for our Early orning and Late-Evening Customers
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mobile Phone
(Required)
Home Phone
Business Phone
Email
(Required)
Year, Make & Model
(Required)
License Plate Number
(Required)
Mileage
(Required)
Color
(Required)
Service Request Checklist
(Required)
Oil & Filter Change
C/V Joints
Fluid Leak
Service Lights
Maintenance Interval
Steering Concern
Belts/Hoses
Fuel System
Brakes
Air Conditioning
Exhaust
Trip Check
Suspension Concern
Cooling System
Transmission
Electrical
Other
If you selected "Other" please explain
(Required)
Symptoms
(Required)
Hard to Start
Misses
Smokes
Stalls
Pings
Brake Pulls
Runs Poorly
Clicks on Turns
Brake Noise
Hesitation
Shudders
Brake Pulsation
Other
If you selected "Other" please explain
(Required)
Circumstances
(Required)
When Cold
When Accelerating
When Hot
When Turning
When Braking
Not Applicable
Other
If you selected "Other" please explain
(Required)
Notes
Please read carefully, check one of the statements below and sign:
(Required)
I request a written estimate. Chad Miller Auto Care will perform NO services until a verbal estimate is provided.
I do not request a written estimate as long as the repair costs do not exceed $____ (please fill out the amount below). The shop may NOT exceed this amount without my written or oral approval.
I would like my old parts upon completion of repair.
Max amount of approved repair cost
(Required)
By typing your name you understand that there is a diagnostic fee of $139.95 and all the information listed is the best to your knowledge.
(Required)
Please type your full name in place of a signature.
Date
(Required)
MM slash DD slash YYYY
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