Fireplace Service Request

Full Name *

Address *

City

State

Zip Code

Phone*

Email Address *

Have you used Southwest Fireplace in the past? -Previous CustomerNew CustomerNew Customer - referred by manufacturer ***If Referred by manufacturer - Please provide the following information:

Manufacturer —Please choose an option—HeatlilatorHeat & GloVermont CastingQuadraFire Model Number Serial Number

Type of Fireplace *—Please choose an option—Wood Burning - MasonryWood Burning - PrefabricatedDirect VentVent FreeStoveInsertOtherUnsure

Type of Fuel*—Please choose an option—WoodGasPelletElectricOther

Describe the issue *

If known, please provide the make, model and/or serial number for your unit?

How do you prefer to be contacted with service options?PhoneEmailEither

How did you hear about us?—Please choose an option—Google SearchDrive ByPrint AdReferralDealer LocatorRadioYelllow Pages OnlineOther