Client Repair Intake Form

CLIENT REPAIR INTAKE FORM

RECITALS

WHEREAS, Client Name: (the "Client") desires diagnostic, repair, maintenance or related services for the Device described below; and

WHEREAS, Service Provider Name: (the "Service Provider") is willing to provide such services under the terms and conditions set forth in this form;

NOW, THEREFORE, the Client authorizes the Service Provider to perform the requested diagnostics and repairs subject to the scope, payment terms, and other terms set forth herein.

CLIENT INFORMATION

DEVICE INFORMATION

PROBLEM DESCRIPTION & DIAGNOSTICS

SCOPE OF WORK

The Service Provider will perform the following work as authorized by the Client. Any additional work beyond this scope will require separate written authorization or approval by the Client and may result in additional charges.

PAYMENT TERMS

Estimated Repair Cost: $

Deposit Required at Authorization: $ — Balance due upon completion and prior to release of Device.

Payment Schedule / Method:

Late Payment Fee: on outstanding balances. Client is responsible for collection costs and reasonable attorney's fees for delinquent accounts.

TERM AND TERMINATION

Service Start Date:    Estimated Completion Date:

Either party may terminate authorization for work by providing written notice to the other party at least days prior to the intended termination. If the Client cancels after work begins, Client remains responsible for labor performed and parts ordered.

CONFIDENTIALITY

The Service Provider shall maintain in confidence any non-public information obtained from the Client in connection with repair work and shall not disclose such information except to employees, subcontractors or suppliers performing the services or as required by law. Confidential information does not include information that is publicly known or independently developed.

LIMITATION OF LIABILITY; STORAGE; TITLE

The Service Provider's liability for any claim arising out of or related to the services is limited to the amount actually paid by the Client for such services. The Service Provider is not liable for data loss, software configuration, or pre-existing damage unless caused by the Service Provider's gross negligence. Devices left unclaimed for more than days may be subject to storage fees of $ per day or disposition under applicable law. Title to replaced parts vests in the Service Provider unless otherwise agreed in writing.

GOVERNING LAW

This agreement and any dispute arising from it shall be governed by the laws of the State of , without regard to conflict of law principles.

ENTIRE AGREEMENT

This form, together with any signed estimates or supplemental authorizations, constitutes the entire agreement between the Client and the Service Provider regarding the subject matter and supersedes all prior negotiations and understandings. Any amendment must be in writing and signed by both parties.

CLIENT AUTHORIZATION

By checking the box below and signing this form, the Client authorizes the Service Provider to perform the diagnostic and repair services described in the Scope of Work, to order and install parts necessary to complete the repair, and to charge the payment method on file for authorized amounts including deposits and applicable fees.

I authorize repairs and accept the terms and conditions set forth in this Client Repair Intake Form.

I authorize the Service Provider to proceed with additional work up to $ without further approval. If left blank, no additional work will be performed without client approval.

Sign Now