WEB FORM - MIROMAX PDR

1

Please provide your First Name* This field is required.

2

Your contact Phone* This field is required.We may need to contact you about the dent or arrange for repair.

3

Please provide your contact Email* This field is required.We will never, ever use it for any purpose but to contact you about THIS repair. No Spam -- We promise!

5

What is the approximate size of the dent or Dent(s)* This field is required.Choose all that apply. Size is from edge to edge at the longest point on the dent or crease.

AUTO HAIL REMOVAL

1" or greater

2" to 3"

4" to 5"

5" to 7"

8" to 10"

The dent is 'bigger'

6

Please Enter the Vehicle YEAR, MAKE & MODEL* This field is required.Please provide this vital information so we can give you the most accurate quote possible

7

If you're taking a photo of your dents.... here is a handy tip:

8

We need at least two good angles to assess the damage. (required)* This field is required.Please upload your photos. If your are unable to add photos, please bring in the vehicle to be estimated.

Drag and drop files here

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Max. file size: 10.6MB

9

How did this dent happen?Please provide any details about how the dent occurred (if known)