Mobile Device Service & Repair
BOOKING FORM (CUSTOMER INTAKE) — PAGE 1 OF 2
Ph: (02) 0000 0000
demo@repairbench.com.au
https://www.repairbench.com.au
ABN: 00 000 000 000
demo@repairbench.com.au
https://www.repairbench.com.au
ABN: 00 000 000 000
Job Reference
Customer & Device Information
First Name
James
Last Name
Patterson
Date of Birth
OS Version
iOS 18.3
Mobile Phone
0407 218 663
Alt. Phone
Email Address
james.patterson@example.com
Network / Carrier
Street Address
33 High St
Suburb
Toowong
State
QLD
Postcode
4066
Brand / Make & Model / Series
Apple iPhone 11
How Did You Hear About Us?
Demo seed
Colour
Black
Storage
64GB
Passcode / PIN
5521
Device Type
Smartphone
IMEI (dial *#06# or Settings › About › Status)
353998104477201
Serial Number
C39ZX10QP7
Device Condition on Arrival
| Component | OK | Minor | Major | N/F | N/A | Component | OK | Minor | Major | N/F | N/A | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Screen / Display | Buttons / Controls | |||||||||||
| Back Cover / Body | Front Camera | |||||||||||
| Charging Port / USB | Rear Camera(s) | |||||||||||
| Headphone Jack | Speaker / Microphone |
Condition Notes / Additional Damage Observed
Accessories Received
USB-C / Lightning Cable
Power Adapter / Plug
Protective Case
Screen Protector
SIM Card
Memory / SD Card
Earphones / AirPods
SIM Eject Tool
Fault Description & When Does Fault Occur?
Fault Description / Issues Reported by Customer
Screen cracked and rear glass shattered after a fall down stairs.
When Does Fault Occur?
☐ Always
☐ Intermittently
☐ After Charging
☑ After Drop
☐ After Liquid
Customer Authorisation & Disclaimer
By signing below I confirm: (1) I am the owner or am authorised to act on the owner's behalf; (2) I authorise the business to inspect, diagnose, and provide a written repair quote; (3) I am solely responsible for backing up all data — no liability is accepted for data loss during service; (4) Repairs will NOT proceed without my authorisation of the quoted price; (5) A diagnostic/assessment fee may apply if a quoted repair is declined after inspection; (6) Devices uncollected after 60 days may be recycled or disposed of. Diagnostic fee of $82.50 applies if quoted repair is declined. Devices uncollected after 60 days may be disposed of. All prices include GST. 30-Day Parts & Labour Warranty.
Customer Signature (Intake)
Print Full Name
James Patterson
Date
15/06/2026
Contact Preference:
☐ Phone
☐ SMS
☑ Email
☐ In-Person
Max. Spend: $___________
Repairs will NOT proceed without written or verbal approval.
Collection Sign-off — completed when the device is collected
Customer Signature (Collection)
Received in good order
I confirm I have collected my device and that I am satisfied with the work performed. I have inspected the device and accept it in good working order.
Date