J P Auto Repair Brake Service
(print & bring in for expedited service)
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Date __________________________
Name ___________________________________________________
Address _________________________________________________
Phone Numbers __________________________________________
Vehicle Make ________________________ Model ____________________ Year __________
BRAKE SYMPTOM SERVICE
Help our technicians help you.
1. Does your car stop OK?
Yes No Sometimes
2. The brake pedal seems:
To work OK Too high To pulsate or chatter
Hard Too low To work better when pumped
Soft Spongy To return too slowly
3. Does the vehicle:
Stop straight Pull left only when braking Always pull in one direction
Pull right only when braking
4. Do the brakes:
Grab Seem to be dragging Lock at times Make noise
Describe noise:________________________________________________________
5. The Emergency/Park Brake:
Is seldom used Works OK Doesn't work properly
Explain:_______________________________________________________________
6. Has the brake fluid been adding in the last 6 months?
Yes No
7. Have the brakes been flushed and bled in the last 6 months?
Yes No
Adjusted?
Yes No
8. Is dash brake light on?
Yes No
9. Last time brakes were serviced and repaired?
3 Months 6 Months 9 Months Longer
10. Other problems:________________________________________________________________
_________________________________________________________________________________