Declined Service Recommendation Customer Sign-Off Form

Customer-signed acknowledgment of recommended repairs or services that were offered and declined, capturing the reason for refusal, associated risks, and a liability release — used to support follow-up outreach and protect the business from future claims.

Visit & Service Advisor Details

• Date of Service Visit
• Work Order / RO Number
  The repair order or job number associated with this visit.
• Service Location / Branch
• Service Advisor Name
• Advisor Employee ID

Customer Information

• Customer Full Name
• Customer Phone Number
• Customer Email Address
• Vehicle / Asset Identifier
  Enter the VIN, serial number, or other unique identifier for the item being serviced.
• Year / Make / Model (if applicable)
• Current Mileage or Operating Hours
  Record at time of visit for service interval tracking.

Declined Recommendation Details

• Category of Declined Recommendation
  Select all categories that apply to the declined recommendation(s).
• Detailed Description of Recommended Service(s)
  Be specific and observable. Include measurements, part names, and urgency level where applicable.
• Urgency Level of Declined Service
• Estimated Cost Presented to Customer (USD)
  The quoted or estimated cost shown to the customer at time of recommendation.
• Supporting Documentation (Photos, Inspection Report)
  Attach photos, digital inspection reports, or other evidence supporting the recommendation.

Customer's Reason for Declining

• Primary Reason for Declining
• Please Describe
• Does the Customer Intend to Return for This Service?
• Preferred Follow-Up Date (if returning)

Risk Disclosure & Liability Acknowledgment

• Risk Disclosure
  NOTICE TO CUSTOMER: By declining the recommended service(s) listed above, you acknowledge that you have been informed of the potential risks, which may include — but are not limited to — reduced safety, equipment failure, voided warranty coverage, regulatory non-compliance, or increased repair costs if the condition worsens. The service provider is not responsible for any damage, injury, loss, or liability arising from your decision to decline the recommended service(s).
• I understand there may be safety risks associated with declining this service
• I release the service provider from liability for issues arising from my decision to decline
• I understand this decision may affect my warranty or compliance status (if applicable)
• I consent to being contacted by the service team to follow up on the declined recommendation
  Optional. You may opt out of follow-up contact at any time by contacting the service location.

Customer Signature

• Customer Signature
  Sign to confirm you have read, understood, and agreed to the terms above.
• Date Signed
• Service Advisor Signature (Witness)
  Advisor signature confirms the recommendation was presented and the customer's decision was documented in their presence.
• Internal Notes (Not Visible to Customer)
  These notes are for internal use only and will not appear on the customer copy.