Name (Business or Personal)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone
Email
1. How many persons reside/ work in the home/office?
2. Approximately what year was the structure constructed?
3. List any existing health conditions of persons in the home/office:
4. Expectant mother?
Yes No
5. What is the source of water?
Municipal
Private System
Well (Pre-treated)
Well (untreated)
Other
6. If on a well, can you provide us with a water quality report?
Yes No
7. Would you like us to provide you with your local water report?
Yes No
8. Do you have poor taste or bad odors in your water?
Yes No
9. Are you aware of any other problems in your water?
Bacterial contamination
Arsenic
Lead
Fluoride
Radon
Other
10. Do you currently have any form of in-home/office water treatment?
Reverse osmosis
Carbon filter
Faucet filter
Pour thru pitcher
Other
11. Do you use bottled water in the home/office or on the road?
Yes No
About how much money is spent monthly on drinking water?
If consuming bottled water, which brand(s) do you buy most often?
12. Do you use a water softener or other point-of-entry/whole home system?
Yes No
13. The quality of water used for bathing/showering is also critical. Are you interested in receiving information on whole home/office treatment systems?
Yes No
Comments/ questions
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