Intake Form

New Customer Intake Form
Date

MonthDayYear
Date
How did you hear about us?
Please Specify Referral
Full Name*

First NameLast Name
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Pool Information
Timer
Gallons
Type of Filter
Weekly Service
Motor Info
Spa

YesNo
Water Type

SaltChlorine
Polaris Cleaner

YesNo
Filter Pressure
Trees / Shrubs

LowMedHigh
Service Day
Filter Clean Schedule

JanFebMarAprMayJuneJulyAugSeptOctNovDec
Current Pool Issues
Notes For Pool Technicians
Additional Survey Notes
Take Photo
Should be Empty: