Appointment Registration Form

(* Required)

First Name *

Last Name *

Phone Number *

Email *

Address *

City *

State *

Zip Code *

Additional Contact Name
If applicable, name of anyone else that may be present during the appointment.

Alternate Contact
If there is another number or way you would like to be reached.

Your Scheduled Appointment
Leave BLANK if you have not yet scheduled a date and time.
Date:
Time:
Location:

Vehicle *
MAKE, MODEL, and YEAR

Additional Vehicles
If applicable, list any additional cars - Make, Model, Year

Child & Car Seat (Child 1) *
Car Seat MAKE & MODEL
Child's AGE, WEIGHT & HEIGHT (write 'unborn' if applicable)

Child & Car Seat (Child 2)

Child & Car Seat (Child 3)

If more than 3 children or car seats, please include in comments below.

Are there any special healthcare needs or convenience considerations?
(We are trained in Safe Travel for Children with Special Healthcare Needs)

How did you find us?

Additional Information & Comments

Please check out our Service Rates & Appointment Policy
I have reviewed and accept How-To-Safety's Service Rates and Appointment Policy.

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