Name *

First Name

Last Name

Phone *

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Do you: *

Own your home

Rent your home

What kind of water do you drink? *

Tap

Filtered

Bottled

Water issues you may have (check all that apply) *

Is there an odor or smell coming from your water?

Have you noticed any white calcium build-up on your faucets or showerheads?

Do you smell or taste chlorine when you drink the water?

Is there any discoloration of the water?

Do you or your family feel sick or have an upset stomach after drinking the water?

If you have pets, do they feel sick after drinking the water?

Does your skin feel dry, flaky or itchy after a bath or shower?

Do your appliances that deal with water break often or not work as well as expected?

Other