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Full Name
Address
City
Zip Code
Phone Number
Email Address
Please describe the current conditions of your water:
Chlorine smell
Foul odor
Soap scum build up
Shower stains
Toilet stains
Rust deposits/stains
Hazy appearance
Discoloration
Number of persons in household
Do you buy bottled water? How many gallons per week?
Do you own your home?
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Yes
No
Does any family member suffer from dry, itchy skin?
-- Select --
Yes
No
Does your home have a water treatment system?
-- Select --
Yes
No
If yes, what brand?
Water source:
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City
Well
How would you rate your water?
-- Select --
Excellent
Good
Poor
When was the last time your water was tested?
If you could change something about your water quality, what would it be?
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