Professional Ultrasonic Fuel Injector Cleaning  and Flow Testing Services.

                                                            Print this page                             Service Order Form

Please fill out this form and package the injectors in numbered plastic bags. Be sure to keep o-rings and spacers on injectors so we can match with new ones if available. Ship the completed “Service Order” with the injectors to: InjectorRX 12201 Dover St. Houston, TX 77031. Call us at 281-738-3635 with any questions.

CUSTOMER INFORMATION:

Customer Name……………………………….……………… Phone …..…….………………  

Shipping Address.…………………………………………………………………………………………..  

City ……………………………………………….…..State……………… Zip ……………….  

Email ………………………………………………………………..  

Year & Make of Vehicle ……………………………….. Model ……………………………….  

SERVICE REQUESTED (check all that apply)

Standard Shipping ($12) Express Shipping ($39)

Insurance can be purchased for $1 per $100 of coverage.

Please indicate insurance value for your injectors. $..............................................................

                                                    Payment Method: 

1. Credit Card Details: 

Name as it appears on card: …...................................................................  

Card Type…………………………………………………… (Visa, Master, Discover, Amex) 

Card Number …………………………………………………………………… 

Expiration Date……………………………… CSV ……………………………. 

Authorization to use Credit Card:

Signature:…………………………………………...............................Date………………………………………

Or: 

2. Paypal ID……………………………………………………………………………(invoice upon completion)

                           Note: Please indicate any special instructions on the back of the form: