EmailMe Form - Adare Service Call Booking Form

Name *
First Last
Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Email *
Email address required to confirm booking, and is kept strictly confidential
Phone *
### - ### - ####
Would would like to receive our Monthly Tips?
Yes
No
Choose your service from dropdown menu
Choose your urgency from dropdown menu
Choose your Service Type from dropdown menu
Type of equipment
Choose your best time
8:30 AM - 12:30 PM eastern time
12:30 PM - 6:30 PM eastern time
Any time - ASAP
After hours 7:30 PM - 9:00 PM eastern
An added fee may apply after hours
Type of service required
On-site
In shop (I will drop off)
Pick up (Ottawa/Gatineau)
A $12.00 fee applies for pick-up.
Billing Address if different from above

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Business customers only !!
PROBLEM:
Enter problem description, and any error messages you may be receiving
Previous service call #
(if known or applicable)
Preferred Customer #
Payment method
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