Water Quality Questionnaire

Name (required)

Address

Email (required)

Phone Number (required)

Spouse’s Name

Spouse’s Phone Number

Spouse’s Email

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?

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