The power flush company
contact form
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SECTION 1
This section has 7 Questions
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1/7: Are you a:
*
Homeowner
Landlord
Agent
Contractor
Tenant
Gas Engineer
Builder
Carer
Family member
Neighbour
Other
Your business name
Business Address
Street Address
Street Address Line 2
City
tate Province
Postal / Zip Code
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2/7: Enter your name
*
First Name
Last Name
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3/7 : Enter you e-mail address
*
example@example.com
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4/7: Phone Number
*
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5/7: Invoice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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6/7: Is the invoice address same as job address?
*
Yes
No
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6a/7: Job Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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7/7: What type of property it is
*
Please Select
Commercial
Domestic
What type of domestic property it is
*
Please Select
House
Bungalow
Maisonette
End terrace
Mid Terrace
Restaurant
Office
Hospital
Dr’s Surgery
Flat
Output flat
Which floor?
*
Is there an elevator?
*
Yes
No
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We will be in touch shortly! to make a booking for a free survey on your commercial system, so we are able to provide you with an accurate quote.
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Section 2
In this Section we need some information about your boiler and heating system, this section contains 14 questions
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Please select The Type Of Boiler?
output
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2/14: How many boilers do you have?
*
1
2
3
4
5
output i
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3/14: How many Hot water cylinders do you have 0-5?
*
0
1
2
3
4
5
output ii
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4/14: What is the brand and model of the boiler?
*
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5/14: How old is the boiler?
*
Please Select
Don't Know
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output old
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6/14: How many radiators do you have? (Including towel rails)
*
output iii
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7/14: Do you have underfloor heating?
*
Yes
No
How many manifolds do you have?
*
Please Select
1
2
3
4
5
6
7
8
9
10
How many loops per manifold?
Manifold 1
*
Please Select
1
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Manifold 2
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Please Select
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Manifold 3
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Please Select
1
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Manifold 4
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Please Select
1
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Manifold 5
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Please Select
1
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Manifold 6
*
Please Select
1
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5
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Manifold 7
*
Please Select
1
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Manifold 8
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Please Select
1
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Manifold 9
*
Please Select
1
2
3
4
5
6
7
8
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10
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Manifold 10
*
Please Select
1
2
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5
6
7
8
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19
20
output iv
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8/14: Do you have a microbore system? (Pipe work 10mm)
*
Yes
No
output v
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9/14: Do you have a manifold?
*
Yes
No
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10/14: Do you have twin entry valve?
*
Yes
No
twin entry ouput
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11/14: Do you have solar heating system?
*
Yes
No
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12/14: When was the last time your heating system was flushed
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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13/14: Are you experiencing any of the following symptoms
*
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14/14: Do you have a magnetic filter?
*
Yes
No
Do you want us to install one?
*
Yes
No
output vi
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Section 3
In this section you will be asked some general information, This section contains 3 questions
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1/3: Do you have boiler insurance?
*
Yes
No
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2/3: Do you want us to do any remedial work if required?
*
Yes
No
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3/3: Are there any parking restrictions
*
Yes
No
Please arrange a parking permit as we do not pay for parking
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