Source Water Survey *

What kind of water do you drink? (Pick 1 or more)

Fiji

Dasani

Aquafina

Tap Water

Essentia

Life Water

Poland Spring

Pure Life (Nestle)

Water Softener System

Purification Filter

Other (Explain)

Ever notice spots or stains on dishes and toliets? *

(White spots on dishes/brown ring stains in toilet) (Pick any and all that apply)

Yes

No

Only dishes

Only toilet

Ever experience any of the following with your home shower: *

(Pick any and all that apply)

Skin feels dry

White patches

Red rashes / Itchiness

Skin is "Squeaky Clean"

Hair feels dry and frizzy

The need to apply lotion after shower

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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