Client Check In and Customer Concerns Questionnaire
Are you a New Client or Current Client?
New Client
Current Client
What type of appointment do you have with us?
Repair
Collision
Name
*
First Name
Last Name
Best Phone Number to Contact You
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
City
State / Province
Postal / Zip Code
Email
example@example.com
Year - Make - Model of Vehicle
*
We are ASE Certified Professionals that truly care for our customers and their safety. Our policy is to inspect your vehicle and advise you of any areas of concern. We will not proceed with any repairs without providing you with an estimate and receiving your approval. By checking below you authorize Arizona Auto Repair Center and its employees to inspect and test drive your vehicle and any changes that have previously been agreed upon such as Testing and Procedure charges that start at a minimum of $75.00-$225.00, and could be more depending on hours needed for inspection and diagnosis. We accept debit and credit cards, Snap Financing, and Cash. We offer a 4% discount on all Cash Transactions.
*
I have read the above statement, and Agree
I have read the above statement, and Do Not Agree
The Estimate of Repairs may include parts, labor, diagnosis and any applicable taxes that is bases on our FIRST visual inspection. If, on further inspection, additional parts or repairs are needed, you will be contacted for authorization and/or a supplement will be submitted to your insurance company (if applicable). Unforeseen repairs may be found or may occur during the repair process and you will be notified on how we must proceed with repair and what additional costs will be associated to move forward. By checking below you authorize Arizona Auto Repair Center and its employees to inspect and test drive your vehicle. We do not accept 3rd party insurance checks. If you pay by credit card a 4% fee will be added to the total. Totals quoted do not include this fee. Please have insurance payments sent directly to us to ensure we have no delivery delays. We accept debit and credit cards, Snap Financing, and Cash. We offer a 4% discount on all Cash Transactions.
*
I have read the above statement, and Agree
I have read the above statement, and Do Not Agree
If scheduled for a diagnosis, customer understands they have to have a minimum 1/2 tank of gas when dropping off due to the technicians needing to test drive the vehicle. If tank is empty when vehicle is dropped off, you authorize being charged for the tank to be filled for diagnosis needs. Charge depends on gas prices.
*
I have read the above statement, and Agree
I have read the above statement, and Do Not Agree
Are you the primary decision maker on any necessary repair?
Yes
No
Do you have any other sources of transportation while your vehicle is being worked on?
Yes
No
Customer Concerns Questionaire
Has any work been done within the past 6 months? By yourself or another shop
Yes
No
Other
If yes, was the work done by you, or another shop?
Work was done by another shop
Work was done by me or someone I know
If so, what work was done? (Parts that were fixed or installed, replaced, etc)
Any Warning Lights On?
*
Yes
No
Which Warning Lights are On?
Do you have a Starting Problem?
Yes
No
What starting problems are you having?
Will not crank
Cranks but won't start
Starts but takes a long time
How often?
Every time
Sometimes
Not as often
Outside Temperature when these problems occur?
Cold
Warm
Hot
Wet/Rainy
Doesn't Matter
Problem usually occurs
Morning
Afternoon
Anytime
When did the issue start?
Suddenly
Gradually
Just Started
Been happening for quite some time
Have you replaced
Fuel Filter
Fuel Pump
Battery
Spark Plugs
Ignition Coil
Plug Wires
If So, when did you make these replacements?
Do you have a Drivability Issue?
Yes
No
What kind of drivability issue are you having?
Dies at idle
Died while driving
Dies right after it starts
Misfires
As I accelerate
When I put it in gear
While at steady speed
Hesitation
Pulls left or right
Vibrates at certain speed
Loses power at higher speeds
How often?
Every time
Sometimes
Not as often
Outside Temperature when these problems occur?
Cold
Warm
Hot
Wet/Rainy
Doesn't Matter
Problem usually occurs
Morning
Afternoon
Anytime
Vehicle Speed
Low
Cruising
High
Driving Conditions
Short, less than 2 miles
2-10 miles
Long, more than 10 miles
Usually occurs
Stop and go
While turning
In reverse
Downhill
Uphill
Rough road
While shifting gears
While braking
AC on
How often do you service your engine?
What type of oil do you use?
When did the issue start?
Suddenly
Gradually
Just Started
Been happening for quite some time
Have you replaced
Fuel Filter
Fuel Pump
Battery
Spark Plugs
Ignition Coil
Plug Wires
If So, when did you make these replacements?
Do you have a Transmission Issue?
Yes
No
What type of Transmission issues are you having?
Improper shifting - early
Improper shifting - late
Changes gears randomly on its own
Stuck in neutral
Stuck in park
Revs high
Vehicle won't move when put in gear
When was your vehicle last serviced?
How often?
Every time
Sometimes
Not as often
Outside Temperature when these problems occur?
Cold
Warm
Hot
Wet/Rainy
Doesn't Matter
Problem usually occurs
Morning
Afternoon
Anytime
Gear Selector when in
P
R
N
D
OD
1st
Between Gear Position
1 & 2
2 & 3
3 & 4 (overdrive)
Driving conditions
Accelerating
Decelerating
Braking
Low RPM
Medium RPM
High RPM
Do you have a Noise Problem?
Yes
No
What type of Noise Problems are you having?
Suspension Area
Brake Noise
Engine Compartment
Power Steering Area
How often?
Every time
Sometimes
Not as often
Outside Temperature when these problems occur?
Cold
Warm
Hot
Wet/Rainy
Doesn't Matter
Problem usually occurs
Morning
Afternoon
Anytime
Vehicle Speed
Low
Cruising
High
Idle
Driving Conditions
Short, less than 2 miles
2-10 miles
Long, more than 10 miles
Usually occurs
Stop and go
While turning
In reverse
Downhill
Uphill
Rough road
While shifting gears
While braking
AC on
Have you replaced any of the following?
Timing belt
Timing chain
Belts
Brakes
Power Steering Pump / Rack N Pinion
Ball joints
Tie rod ends
Control arms
Shocks / Struts
Describe the noise
Grind
Chirp
Rattle
Knocking
Whining
Growl
Hiss
Squeal
Clunk
Boom
Hum
Other
Do you have a Overheating Issue?
Yes
No
What type of Overheating issue are you having?
Noticed fluid leak
Vehicle boiled out of fluid
Temp gauge went to the red
How often?
Every time
Sometimes
Not as often
Outside Temperature when these problems occur?
Cold
Warm
Hot
Wet/Rainy
Doesn't Matter
Problem usually occurs
Morning
Afternoon
Anytime
Driving Conditions
Short, less than 2 miles
2-10 miles
Long, more than 10 miles
Usually occurs
Stop and go
While turning
In reverse
Downhill
Uphill
Rough road
While shifting gears
While braking
AC on
In what area did you see fluid?
Under car
Inside of car
Driver side
Passenger side
Middle
Rear
When did the issue start?
Suddenly
Gradually
Just started
Does AC blow cold?
Yes
No
Does Heater work?
Yes
No
Do you have a AC & Heating Issue?
Yes
No
What type of AC or heating issue?
Not blowing cold
Noise
Has a bad smell
Temperature fluctuates
Cuts out
How often?
Every time
Sometimes
Not as often
Outside Temperature when these problems occur?
Cold
Warm
Hot
Wet/Rainy
Doesn't Matter
Problem usually occurs
Morning
Afternoon
Anytime
Vehicle Speed
Low
Cruising
High
Idling
Driving Conditions
Short - less than 2 miles
2-10 miles
Long - more than 10 miles
Problem occurs during
Going downhill
Going uphill
Rough road
Which vents do not work?
Center
Left / Driver Side
Right / Passenger Side
Floor
Defroster
Rear
Which intake cannot be changed?
Fresh / Outside Air
Recirculating Air
Noise Happens
When AC on
Noise increases with engine speed
Noise changes when control lever is moved to change air outlet
Does heater work?
Yes
No
Any noise when heater is turned on?
Yes
No
Do all heater controls work?
Yes
No
Did vehicle overheat?
Yes
No
Not sure
Do you have a Fluid Leaks?
Yes
No
What color is fluid leaking?
Pink
Green
Dark Brown
Black
Reddish Pink
Orange
Location of Leak?
Driver Side Front
Passenger Side Front
Driver Side Rear
Passenger Side Rear
Center of Vehicle
Did the vehicle rise in temperature and get excessively hot?
Yes
No
Did you start to have a drivability issue?
Yes
No
If there is a smell with this issue, what are you smelling?
Sweet
Burnt
Rotten Eggs
Fuel
Moldy
Other
How long have you noticed this concern?
Recently
1-2 weeks
3-4 weeks
Longer
Where is the damage located?
Front End
Rear End
Passenger Side
Driver Side
Other
How will you be paying?
3rd Party
Self Pay
Insurance Pay
If you are using insurance, how much is your deducible?
Insurance Name, Claim Number, and Phone Number, if applicable
Since the accident, has any mechanical issues started?
Yes
No
Is the Check Engine Light on?
Yes
No
Was the Check Engine Light on before or after the accident?
Before
After
Is the vehicle pulling to one side or the other?
Yes
No
Do you have an extended warranty?
Yes
No
What other concerns or symptoms do you have?
Submit
Should be Empty: