Name *

Vehicle (Year/Make/Model) *

Preferred Appointment Date
(We will do our best to accommodate your request. Please do not consider your appointment confirmed until you have received a confirmation from our team) *

Address *

Address

City

State/Province

Zip/Postal

Country

Cell Phone *

Home Phone

Email *

Preferred Contact Method *

Phone Call

Text

Your driver’s side front window will be rolled down when the vehicle enters the shop. Please confirm that there is no known issue that might cause it to get stuck in the down position. *

Yes, it functions normally

No, do not roll it down, it might not come back up

Please tell us more about how you view the vehicles you own or lease. Finding out what is important to you helps us to serve you better. Creating a plan to address your vehicle’s needs tailored just for you saves you both time and money, while also conserving valuable resources.

Please tell us which statement best describes how you think about your vehicle (circle the appropriate number): *

My vehicle is just a machine. It is a means of conveyance that gets me to where I need to go. If this one gets too expensive to operate, or too old, I’ll just trade it in and get another. I like driving new/different cars every few years.

I love my car. I generally keep my cars “until the wheels fall off.” It’s not uncommon for me to hold onto a car for 10 or more years. Cars are more than just machines to me. After a while, they become like a member of the family.

I know it’s just a machine, but this vehicle is very special to me. I have some wonderful memories associated with it and I will likely always keep it.

Do you own or lease the vehicle brought in for service today? *

I own the vehicle I brought today for service

I lease the vehicle I brought today for service

If you lease the vehicle, do you plan on buying it after the lease ends? *

Yes

N/A

Is this vehicle your primary source of transportation? *

Yes

Does this vehicle get used frequently, or is it a “spare” or third car? *

What are your plans for the vehicle in the next 12 months? *

Are there any recent repairs that we should know about (including accidents)? *

Do you currently follow the factory maintenance schedule? *

Yes

How many miles do you usually drive between oil changes? *

Concerns

Please notate why you have brought your car in today:

When/how often does it happen?

Add Remove

I hereby authorize the repair work herein set forth to be performed along with the necessary parts and materials. I agree that Bock Auto is not responsible for loss or damage to the vehicle, or articles left in the vehicle, in case of fire, theft, or any other cause beyond their control. I hereby grant Bock Auto and/or its employees permission to operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing and/or inspection. An express garage keeper’s lien is hereby acknowledged on the above vehicle to secure the number of repairs thereto. All vehicles left over 24 hours after notification of completion WILL INCUR A $40.00 PER DAY STORAGE FEE. *

I have read and understand

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Date *

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Concerns