Spouse’s Phone Number
Has any member of your household experienced any of the following? Check all that apply. Acid Reflux / HeartburnItchy Dry SkinEczema / PsoriasisDry / Brittle Hair
Has anyone noticed your water having a strange odor or smell? Check all that apply. Chlorine / AmmoniaSulfur / Rotten EggMetallic ChemicalEarthy / Musty
Have you recently noticed any of the following regarding your tap water? Check all that apply. DiscolorationIron StainingScale Build-UpMineral DepositsSoap Scum / FilmReplaced Water Heater
What water do you typically drink? Check all that apply. Bottled Water—SinglesBottled Water—GallonsBottled Water—DeliveryAlkaline Bottled WaterReverse Osmosis WaterRefills / WindmillRefrigerated Filtered WaterPour-Thru Pitcher Filtered WaterFaucet-Mounted Filtered WaterTap Water
Have you had your water tested since moving into this home? Check all that apply. Not yet, but I would like to have it tested.We are testing nowNoCan't recall
What is the approximate age of your home? ---New Construction1-3 Years3-10 Years10-20 Years20+ Years Old
What is your water source? ---City WaterCommunity Well / MUDPrivate WellNot yet connected.
When is the best time to contact you? ---8 – 10 AM10 AM – 12:00 NoonNoon – 2 PM2PM – 5 PM5 PM – 8 PMAnytime
Do you have any additional questions for us?