JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Air Conditioning Client Concern Questionnaire
Please answer all of the questions to better give us an understanding of the air conditioning conerns you are having.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Customer information: Please include name, email, phone number, as well as year, make, model, mileage and license plate of vehicle.
*
Your answer
When is the concern occuring?
Always
Sometimes
Rarely
Other:
What exactly is your complaint about the A/C?
No a/c
Insufficient a/c
Odors/leaks (please describe in other)
Drivability problems that occur when a/c is on (please describe in other)
Other:
How often does the concern occur?
All of the time
When engine is hot
When engine is cold
Other:
What is the temperature or conditions outside like when concern occurs?
All the time
Cool
20-30°C
30°C +
Hot/high humidity
Other:
When is the concern occuring under operating conditions?
All of the time
Stop & Go Traffic
Highway Cruising
Under load
Other:
How is the blower fan operation?
Ok
Missing speeds
Other:
How is the air distribution?
OK
No defrost
No panel
No floor
No air recirculation
Other:
How are the temperature controls?
OK
No temperature change
Control switch operation
Other:
When did the concern start approximately?
MM
/
DD
/
YYYY
Any other information you can leave us that might assist in diagnosing your vehicle.
Your answer
Have you already booked an appointment? If not please feel free to use our online booky system at
Butterworth's Online Booking System
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
