{all_fields}

entry={entry_id}&
{Name (Last):1.6}
{E-mail Address:4}
{Contact Phone:3}
{MAKE / MANUFACTURER:5}
{MODEL:6}
{Does your device have a passcode?:21}
{Please enter passcode::22}
{Did you purchase parts or a repair kit from PhoneDoctors.com?:27}
{Please Provide Your Order Number::28}
{Was your device damaged by liquid?:8}
{Will Phone Doctors be soldering or applying heat to your device?:24}
{Describe the problem you are having.:7}
{What should Phone Doctors do when your device arrives?:9}
{Amount quoted?:16}
{Quoted By::18}
{Where should we return your device? (Street Address):2.1}
{Where should we return your device? (Address Line 2):2.2}
{Where should we return your device? (City):2.3}
{Where should we return your device? (State / Province):2.4}
{Where should we return your device? (Zip / Postal Code):2.5}
{Where should we return your device? (Country):2.6}
{How should we mail back your device?:26}
{Company or Organization:19}
{Please Specify Method of Return Shipping & Account Number:29}
{date_mdy}