Patient Intake | The Stove Doc

CLINIC INTAKE

STRICT PROTOCOL: I specialize in Pellet, Gas, and Wood **Heating** appliances. I do NOT Troubleshoot cook stoves, ranges, or ovens.

FULL NAME*

EMAIL ADDRESS* (FOR CALENDAR INVITE)

CELL NUMBER*

FUEL TYPE*

APPLIANCE BRAND*

MODEL NAME/NUMBER*

SERIAL NUMBER*

"CRIME SCENE" PHOTOS (OPTIONAL)

MOBILE: Tap the button, then tap every photo you want to send.
DESKTOP (PC): Hold Ctrl while clicking your files.
DESKTOP (MAC): Hold Command (⌘) while clicking your files.

Include: Firebox, Exterior, UL Label, Venting/Cap, or Trouble Codes.

DETAILED TROUBLESHOOTING NOTES*

Detailed Patient Intake

CLINIC INTAKE