1. Do you feel bad taste or odor to the water? 1. Do you feel bad taste or odor to the water? Yes No

2. After taking a shower, do you feel dry skin? 2. After taking a shower, do you feel dry skin? Yes No

3. Someone in your home is loosing the hair? 3. Someone in your home is loosing the hair? Yes No

4. Do you cook with regular water? 4. Do you cook with regular water? Yes No

5. Do you usually buy water? 5. Do you usually buy water? Yes No

6. What type of water do you buy?

7. How many child live in your home? 7. How many child live in your home? 12345+

8. How many adults? 8. How many adults?12345+

9. Have you have a In-home test water analysis? 9. Have you have a In-home test water analysis? Yes No

9. Have you have a In-home test water analysis? 9. Have you have a In-home test water analysis? Yes No

Do you want to receive a visit of one of our representatives to get a Free In-home Test Water Analysis? Do you want to receive a visit of one of our representatives to get a Free In-home Test Water Analysis? Yes No

Day DayYesNo

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