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Run: Decline of Service Customer Waiver

This waiver documents a customer’s decision to decline recommended service, including the issue, the risk disclosure, and the signed release. Use it to creat...

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Service and Customer Details

Service Date (required)

Date the recommendation was made and the waiver was signed.

Work Order Number (required)

Internal job or work order reference.

Customer Name (required)

Name of the customer or authorized representative signing the waiver.

Service Address (required)

Location where the service was performed.

Technician Name (required)

Name of the technician who explained the recommendation.

Recommended Work and Decline

Recommended Work (required)

Describe the repair, replacement, or corrective action that was recommended.

Did the customer decline the recommended work? (required)

Select Yes only if the customer is refusing the recommended work.

Reason for Declining

Select all reasons provided by the customer.

Other Reason for Declining

Provide details if 'Other' was selected.

Risk, Code Violation, and Liability Acknowledgment

Issue Type Disclosed (required)

Select all issue types explained to the customer.

Risk or Code Violation Description (required)

Describe the specific risk, code issue, or consequence of not performing the recommended work.

Customer Acknowledgment (required)

Customer confirms they understand the disclosure and the consequences of declining service.

Yes No N/A

Was an emergency shutdown or immediate action advised? (required)

Indicate whether the customer was advised to stop using the equipment or take immediate protective action.

Immediate Action Notes

Document any shutdown instructions, temporary precautions, or follow-up recommendations.

Customer Signature and Release

Release of Liability (required)

Customer agrees that the provider is not responsible for issues arising from the declined work, except where prohibited by law.

Yes No N/A

Customer Signature (required)

Signature of the customer or authorized representative.

Signature Date (required)

Date the customer signed the waiver.

Customer Email

Optional email address for sending a copy of the signed waiver.

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