Run Declined Service Recommendation Customer Sign-Off Form — Free

Visit & Service Advisor Details

Date of Service Visit (required)

Work Order / RO Number (required)

The repair order or job number associated with this visit.

Service Location / Branch (required)

Service Advisor Name (required)

Advisor Employee ID

Customer Information

Customer Full Name (required)

Customer Phone Number (required)

Customer Email Address

Vehicle / Asset Identifier (required)

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 (required)

Select all categories that apply to the declined recommendation(s).

Detailed Description of Recommended Service(s) (required)

Be specific and observable. Include measurements, part names, and urgency level where applicable.

Urgency Level of Declined Service (required)

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 (required)

Please Describe

Does the Customer Intend to Return for This Service? (required)

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 (required)

Yes No N/A

I release the service provider from liability for issues arising from my decision to decline (required)

Yes No N/A

I understand this decision may affect my warranty or compliance status (if applicable)

Yes No N/A

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.

Yes No N/A

Customer Signature

Customer Signature (required)

Sign to confirm you have read, understood, and agreed to the terms above.

Date Signed (required)

Service Advisor Signature (Witness) (required)

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.

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Run: Declined Service Recommendation Customer Sign-Off Form

Visit & Service Advisor Details

Customer Information

Declined Recommendation Details

Customer's Reason for Declining

Risk Disclosure & Liability Acknowledgment

Customer Signature

Get your results