Repair Request Form

Litchfield Park Pool Service LLC

4900 N Litchfield Rd Ste A ● Litchfield Park AZ 85340

623-935-5121 ● litchfieldparkpool.com
Repair Request Form
Current Date *

Month Day Year
Date
Customer Information
Name *

First Name Last Name
Would we find you in our database because we have been to this property before or have made a major purchase such as a cleaner, pump, motor, etc.? *

Yes No
Do you have a home warranty that covers the cost of repairing or replacing pool equipment breakdown or repair? Performing unauthorized repairs could void your home warranty *

Yes No
Best Phone Number *
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email *
example@example.com
Confirm Email *
example@example.com
How do you prefer to be contacted - text or e-mail? *
example@example.com
Pool Address

Street Address

Street Address Line 2

City State

Zip Code
Describe Chief Complaint

Issue with motor, pump, in-floor cleaning system, salt cell, heater or other.

What issues are you having? *

Upload photos of the equipment that needs repair

Cancel of
Was the equipment listed above been repaired within the last 30 days for the same issue? *

Yes No
Do you have dogs? *

Yes No
Do you have a lock on your gate? *

Yes No
What subdivision are you in blank ?

What are your major crossroads blank ?
Are you in a gated community? *

Yes No
Do you want to be called BEFORE THE REPAIR TECHNICIAN HEADS OUT? *

Yes No
Do you want to be there WITH THE REPAIR TECHNICIAN AT THE TIME OF REPAIR? *

Yes No
Payment method - Payment is Due Upon Completion of the Work *
The card on file will be used unless other arrangements have been made prior to the work being completed.
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Do you have any special instructions?
Notes and Reminders
Once we receive this form submission, we'll call you over the phone to make sure that we have the correct information.
Accounts due beyond 10 days are subject to a $25.00 fee to pursue payment and/or submitted to an outside collection agency.
File Upload

Cancel of
Please verify *
Should be Empty: