| First Name: |
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| Last Name: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Home Phone: |
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| Work Phone: |
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| Ext.: |
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| Cell Phone: |
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| Email Address: |
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Privacy Notice: Your email address is held confidential and will never be sold.
Please help us estimate the time needed for your project!
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| How Many Stories is Your Home: |
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| Your Entire House is Approx. How many Sq. Ft? |
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| Do You Have Pets? |
Yes
No |
| Do You Have Children? |
Yes
No |
| Any Children Under 5 Years Old? |
Yes
No |
| Do You Own a Home-Type Carpet Cleaner? |
Yes
No |
| When Was The Last Time You Hired Someone to Clean Your Carpet |
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Check The Box Next To The Room(s) That You Need Cleaned: |
| Living Room: |
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Master Bedroom: |
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| Family Room: |
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Bedroom #1: |
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| Dining Room: |
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Bedroom #2: |
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| Kitchen: |
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Bedroom #3: |
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| Office: |
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Other: |
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| Study: |
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Other: |
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| Den: |
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Other: |
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| Hallway: |
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Other: |
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If you have any special areas of concern, such as pet odors, stains or food and drink stains that will
require additional attention, please tell us about them so that we can accurately schedule the time necessary to
complete your project. If you have pet odor concerns, please include the following information: Is it is a dog(s),
the age, weight and breed, please include the gender as well. Is it is a cat(s) gender and age. Also please indicate
weather the pet is currently taking any medication. If the stain is food or drink based, included the nature of the
spill and how long is been present (if known).
Areas of concern requiring special attention:
Request a Furniture/Mattress Cleaning Estimate: |
| Sofa: |
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Chair:
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| Recliner: |
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Over-stuffed Chair: |
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| Dining Room Chair: |
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Sectional Sofa (# of seat cushions): |
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| Chaise: |
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Wing-Back Chair: |
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| Love Seat: |
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Mattress Sanitizing |
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| Ottoman: |
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Be sure to indicate if is leather or not in the comments field below.
Do you have any stains or areas of concern on your furniture or mattress other than normal soiling?
If so, please indicate wich piece and the nature of the concern.
Schedule Your Own Appointment Time and Date: |
| 1st Choice Date: |
mm/dd/yy |
1st Choice Time: |
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| 2nd Choice Date: |
mm/dd/yy |
2nd Choice Time: |
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| 3rd Choice Date: |
mm/dd/yy |
3rd Choice Time: |
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Or Simply select these appointment options:
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Please contact and inform me what available options i have for This Week: |
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Please contact and inform me what available options i have for Next Week: |
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Please contact and inform me what available options i have for Next Month: |
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In most cases we will contact you back withing 3 hours or by noon on the following business day.
If We Should Have Any Question About Your Project |
| Do we have permission to call you at work? |
Yes
No |
| If necessary, how late in the evening would you accept our call? |
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| Would you prefer we contact you through e-mail? |
Yes
No |
(If you are requesting an appointment within the next 48 hours, we will need to contact you by phone to verify.)
How did you hear about us?
Please let us know what you think about our website, what you liked or didn't like. Especially what you feel would
have made this experience better or easier one to use.
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