YOUR PERSONAL INFORMATION
Full Address
*
Phone Number
*
Email
*
How would you like us to communicate with you?
*
Please Select Email Text Phone Other
How would you like us to communicate with you?
YOUR VEHICLE INFORMATION
Color
*
Year
*
Make
*
Model
*
Vin Number (Optional)
License Place State (Optional)
License Plate Number (Optional)
SERVICES REQUESTED
What is your reason for visiting?
*
Please Select ROUTINE MAINTENANCE CONSULTATION SPECIFIC REPAIR Other
What is your reason for visiting?
What kind of Maintenance?
*
Please Select NO REGULAR SERVICE NEEDED ROTATE AND BALANCE TIRE PRESSURE WIPER BLADES TURN SIGNALS TRANSMISSION SERVICE PREPARING FOR TRAVEL VEHICLE INSPECTION TIRE INSPECTION LUBE, OIL AND FILTER (Oil Change) Other
What kind of Maintenance?
What is your vehicle doing that you do not like?
Please Select SOUNDS NOISES VIBRATIONS LEAKING SMELLS CHECK ENGINE LIGHT OTHER LIGHTS (TPMS, ABS, BATTERY, OIL, COOLANT, MAINTENANCE REQUIRED) Other
What is your vehicle doing that you do not like?
In your own words, what is your vehicle doing that you do not like?
Is your vehicle under the original manufacturer's warranty?
*
Please Select Yes No Not Sure
Is this vehicle covered under an extended warranty? Please provide any warranty information you may have
Please provide a brief history of previous repairs (Please do not list any repairs done by Brian's Tire & Service)
After the baseline inspection is performed, you will be contacted with an estimate for the next step in the process, which may be another test or a list of required and suggested repairs.
What unusual noises are you hearing from your vehicle?
Please Select None Squeaking Grinding Humming Other
What unusual noises are you hearing from your vehicle?
When do you hear this noise?
Please Select Early in the morning Mid-day Early evening Late evening After it has rained Temperature Constantly Occasionally Rarely Other
When do you hear this noise?
Have you had any recent work done on the vehicle before noticing the noise? Are specific actions or conditions triggering the noise (e.g., braking, accelerating, turning)?
Please Select Braking Accelerating Turning Going up a hill Going down a hill Someone is riding in the vehicle with you Someone is riding where in the vehicle Other
Have you had any recent work done on the vehicle before noticing the noise? Are specific actions or conditions triggering the noise (e.g., braking, accelerating, turning)?
When did you first notice the shaking? (e.g., specific date or after a particular event)
How frequently does the shaking occur?
Please Select Every time I drive Occasionally Rarely When Braking Shaking only occurs in mornings Shaking only occurs in afternoons Shaking only occurs at night Other
How frequently does the shaking occur?
Does the shaking become more intense as you accelerate?
Please Select Every time I drive No Not sure Other
Does the shaking become more intense as you accelerate?
Does the shaking reduce or stop when you apply the brakes?
Please Select Every time I drive No Not sure Other
Does the shaking reduce or stop when you apply the brakes?
Is the shaking more pronounced in a specific part of the car? (e.g., steering wheel, seat, front, back)
Does the shaking occur more frequently under certain driving conditions?
Please Select Wet roads Bumpy roads Turning corners Going Uphill Other
Does the shaking occur more frequently under certain driving conditions?
If you said yes above, please describe
When was the last time you had your tires balanced or rotated?
When was your last vehicle inspection or maintenance service?
Have there been any recent repairs or modifications to the vehicle?
Besides the shaking, are there any other unusual noises or behaviors you've observed from your vehicle?
What fluids are you seeing from your vehicle?
Please Select Clear Red Green Blue Brown Black Other
What fluids are you seeing from your vehicle?
Where do you notice the fluid leak?
Please Select Under The Car Under The Hood Both Other
Where do you notice the fluid leak?
If the leak is under the car, please specify the location
Please Select Right Front Left Front Right Rear Left Rear Center
If yes, can you describe the smell?
What are your expectations of Brian's Tire & Service?
What day would you like an appointment?
How will you be paying during your visit?
Please Select CASH CHECK VISA MASTERCARD AMEX BRIAN'S TIRE & SERVICE CREDIT CARD (TWELVE MONTHS INTEREST FREE) SYNCHRONY CARD WEX WRIGHT EXPRESS DISCOVER CREDIT CARD Other
How will you be paying during your visit?
Signature
If you are human, leave this field blank.
