Price Diesel Performance Intake

1. Customer Information

Customer / Business Name *

Phone *

Street Address *

City *

State *

ZIP *

Email *

Other Authorized Person

Other Authorized Phone

2. Vehicle Information

Year *

Make *

Model *

Mileage In

VINVIN is preferred. If VIN is not entered, License Plate and State are required for vehicle lookup.

License Plate

Plate State

3. Customer Complaint

Select everything the customer wants us to know about. These items become part of the customer complaint; they do not automatically add repair jobs.

Describe the concern / requested service *

Intended Payment Method *

Save Old Parts? *

Written Estimate Authorization *

I REQUEST A WRITTEN ESTIMATE. I DO NOT REQUEST A WRITTEN ESTIMATE AS LONG AS THE REPAIR COSTS DO NOT EXCEED A SET AMOUNT. I DO NOT REQUEST A WRITTEN ESTIMATE.

The selected option will be marked on the actual Price Diesel intake form shown on the next page.

4. Review & Sign

This is the exact Price Diesel Performance master intake form. Your information is placed onto the original shop form so you can review the rates, diagnostic fee, authorization language, and legal terms before signing.

Customer Signature *

By signing, the customer acknowledges and agrees to the authorization and terms shown on the intake form above.

PRICE DIESEL PERFORMANCE

1. Customer Information

2. Vehicle Information

3. Customer Complaint

4. Review & Sign

Customer Signature *