Repair Service Intake Form

This form is used to capture essential customer information, equipment details, and the reported issues for any repair service request. This helps the repair team assess, track, and resolve issues efficiently while maintaining clear documentation.

Customer Information

Full Name: {fullName}

Phone Number: {phoneNumber}

Email Address: {email}

Preferred Contact Method: {contactMethod}

Address: {address}

Device Information

Device Type: {deviceType}

Brand: {brand}

Model: {model}

Serial Number: {serialNumber}

Purchase Date: {purchaseDate}

Issue Details

Description of Problem:

{issueDescription}

{#hasPhysicalDamage}

Physical Damage Present: Yes

Damage Description:

{damageDescription}

{/hasPhysicalDamage}

{^hasPhysicalDamage}

Physical Damage Present: No

{/hasPhysicalDamage}

{#additionalIssues}

Additional Issues

• {issue}

{/additionalIssues}

Accessories Submitted

Please list any accessories the customer submitted with the device (e.g. charger, case).

{#accessories}

• {item}

{/accessories}

Warranty and Insurance

Is the device under warranty? {underWarranty}

{#hasInsurance}

Insurance Provider: {insuranceProvider}

Policy Number: {policyNumber}

{/hasInsurance}

{^hasInsurance}

Insurance: Not Provided

{/hasInsurance}

Service Preferences

Request Type: {requestType}

Preferred Completion Date: {preferredCompletionDate}

Technician Notes:

{technicianNotes}

Customer Acknowledgment

I, {fullName}, acknowledge that the above information is accurate to the best of my knowledge. I agree to the terms and conditions for repair services provided by the service center.

Customer Signature: _____________________________

Date: {signatureDate}