Client Intake

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.
Area Code
Phone Number
5
Which water source will your sample be from?* This field is required.
Private Well
City Water
Natural Spring or Artesian Well
6
Please describe your water concerns in as much detail as possible* This field is required.Be specific. Include colors, describe tastes, include length of time you have experienced a specific issue...For instance, instead of saying, "I have stains," say, "I have brown stains that appear around the drains in the bathroom sink. I need to clean them every 2 weeks."
Huge
Large
Normal
Small
Ok
Ok
7
What filtration systems do you currently have in place?* This field is required.
e Traditional Water softener (salt/brine tank)
Water Conditioner (Salt-free)
Iron Curtain or other iron filter
Activated Carbon
Sediment Filter
Reverse Osmosis
Other carbon Filter
No filtration
Other
8
Please describe the lineup of filters in your home* This field is required.For instance: First through the iron curtain, then the water softener and finally the reverse osmosis under the kitchen sink"
Huge
Large
Normal
Small
Ok
Ok
9
Select any problems that are currently occurring with your water* This field is required.
Metallic taste/odor
Chlorine or chemical taste/odor
White or gray residue or scaling
Brown or reddish-brown stains
Black stains
Decreased water pressure
Cloudy or discolored water
thiDry skin/hair after showering or bang
Other bad taste/odor
No problems. I'm just curious what's in my water.
Other
10
Select all that apply* This field is required.
aI do not drink my tap water due to bad taste
I do not drink my tap water because I am worried it is unsafe
I clean stains at every 2 weeks or more
I am replacing filters more often than I am supposed to
I have a separate faucet that is reserved for unsoftened water
I would rather be drinking minerals (electrolytes) than pure water (nothing but water)
I am concerned about my health when drinking the sodium ions that come from a water softener
I notice white residue even in the softened water
I am not sure if bottled water is safe
None of the above
11
Have you ever noticed a rotten egg smell coming from one or more of your faucets?* This field is required.
YESNO
12
If you do smell rotten eggs, now run a faucet in which you smell it on COLD for 30 seconds. Do you notice the smell?
Yes, continuously
Yes, at first, then it goes away
No, not at all
13
If you do smell rotten eggs, Run a faucet in which you smell it on the HOT setting for 30 seconds. Do you notice the smell?
Yes, continuousy
Yes, at first, then it goes away
No, not at all
14
Any comments you would like to add?
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Large
Normal
Small
Ok
Ok
15
I would like to book a 30 minute phone call to go over my results with a water quality specialist. ($45)* This field is required.We wil email you a booking link when your samples have been processed.
YESNO
16
My Products* This field is required.
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My Bag
1
My Bag
Great Product Name
$20
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
The Basics
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The Extras
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Virtual Consultation
You will be emailed a booking link once your samples have been processed.
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EWG Interpretation Report
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Mailing Fee

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Total cost
Payment Methods
Credit Card
First Name
Last Name
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