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Mr. Mrs. Ms.   

  
Name
  
Address
  
City
  
State
  
Zip
  
Email
  
Telephone
  
Homeowner
 Yes No  
Number of bathrooms
 
Age of home
 
City water (RWD)
Yes No  
Well water
Yes No  
Concerns (smell, staining, etc.)
 
Currently using water filtration
Yes No  
If yes please explain
 
Bottled water drinkers
Yes No  
Central heating/cooling
Yes No  
Types of air filters used
 
Number of air returns
 
Any additional comments
  
     
   

David M. Evans, Healthy Home Technologies     P.O. Box 452290 Grove, OK 74345     Telephone: 918-787-1045 or 888-460-7554
   Email: Healthy Home Technologies