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Generic Appointment Triage Form
Please answer the following questions to begin scheduling your session.
*
Indicates required field
Company Name / Member Name
*
Select your current member plan
*
Select One
Plan A
Plan B
Plan C
Non-member with Retainer
Your Name
*
First
Last
Phone Number
*
Extension
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Device Type
*
Choose One
Desktop Computer
Laptop / Notebook Computer
Android Tablet
Apple Tablet
Android SmartPhone
Apple SmartPhone
Internet / Network Equipment & Connectivity Device(s)
Network Printer / Copier / Fax
WiFi Equipment
Voice Communications
VOIP Telephony / Telephone
Operating System
*
Choose One
Windows 10
Windows 8 or 8.1
Windows 7
Mac OSX
Android Phone or Tablet
iPhone or iPad
N/A
Is your Anti-Malware / Anti-Virus software up to date with a valid subscription?
*
Choose One
Yes
No
I don't know
Are you currently able to access the internet from your device?
*
Choose One
Yes
No
What can I help you with?
*
Please be as detailed as possible.
Are you completely down right now?
*
Choose One
I don't know
Yes
No
Next - Schedule Appointment