Customer Intake Form

Fill this out before your visit and we can get straight to work when you arrive.

Before you submit: This form is submitted electronically to FixedIt PC. You will still need to sign the Customer Agreement in person before service begins. Fields marked * are required.

// Customer Information

Full Name *

Phone Number *

Email Address *

Street Address

City

State / ZIP

// Device Information

Device Type *

Make / Brand *

Model

Serial Number

Operating System

OS Version

Physical Condition on Arrival *

Good — No visible damage Fair — Minor scratches / wear Poor — Visible damage / cracks

Condition Notes (describe any existing damage)

Items Included with Device

Power Adapter / Charger Power Cable Mouse Keyboard Monitor External Drive USB Devices Disc in Drive Carrying Case / Bag Other Cables

Other Items / Notes

// Device Login Credentials

Only provide credentials if login is needed to perform the service. All credentials are stored securely and destroyed upon job completion. We recommend changing your password after service as a general security precaution.

PIN (if applicable)

// Service Requested

Primary Service Requested *

Virus / Malware Removal Slow PC Tune-Up OS Install / Reinstall Hardware Upgrade Data Backup / Restore New PC Setup Diagnostic Only Other

Problem Description / What's Happening *

Troubleshooting Already Attempted

Data Backed Up?

Yes No N/A

OK to Wipe / Reinstall OS if Needed?

Yes No Ask First

Drive Destruction Requested?

Yes (+$25) No

By submitting this form, you acknowledge: The information provided above is accurate. You have been advised to back up all data prior to service. FixedIt PC is not responsible for pre-existing hardware conditions, data loss, or software issues unrelated to the requested service. You will be required to sign the Customer Agreement in person before service begins.

✓ Form Submitted

Your intake form has been received. Sascha will be in touch shortly to confirm your appointment.

Questions? Call or text (386) 227-7708

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