Mobile Device Repair Intake & Diagnostic Evaluation Form
Use this form to submit your device for repair, describe the problem, and record diagnostic and service preferences.
Customer & Device Intake
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Device Type
*
Please Select
Smartphone
Tablet
Laptop
Smartwatch
Other
Brand / Manufacturer
Model
Color or Storage Variant
Under Warranty?
Yes
No
Not Sure
Purchase Date
-
Month
-
Day
Year
Date
Repair Request & Diagnostic Details
Primary Problem Description
*
Symptoms Observed
*
Not charging
Screen damage
Battery drain
Water damage
Overheating
No power
Audio issue
Camera issue
Software issue
Other
When Did the Issue Start?
*
-
Month
-
Day
Year
Date
Issue Behavior
*
Intermittent
Constant
Prior Repair History
No prior repairs
One prior repair
Multiple prior repairs
Unknown
Troubleshooting Already Attempted
Restarted device
Charged with different cable or adapter
Tried another power source
Removed accessories or case
Updated software
Reset settings
None
Other
Accessories Submitted With Device
Charging cable
Power adapter
Case
Screen protector
SIM tray tool
Headphones
Memory card
Other
Visible Physical Condition at Check-In
*
Excellent
Good
Fair
Poor
Severely damaged
Diagnostics Notes / Findings
Additional Diagnostic Details
Repair Authorization & Service Preferences
Preferred Service Type / Priority
*
Standard Repair
Expedited Repair
Diagnostic Only
Same-Day Service
Other
Estimate Approval
*
Approve up to quoted estimate
Contact me if the estimate changes
Do not proceed without approval
Permission to Back Up or Erase Data If Required
*
Permission granted for backup only
Permission granted for backup and erase if necessary
Do not back up or erase data
Parts Preference
Original parts
Compatible parts
Either is acceptable
Not sure / advise me
Pickup / Return Preference
*
Pick up in store
Return by courier
Local delivery
Ship back to me
Other
Special Instructions
Preferred Contact Method
Submit
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