Air 2 Water 4 You

           

               WHAT ARE YOUR HEALTH CONCERNS?

First Name           Last Name
   

AREA OF MAIN CONCERN

City Nearest to you in Florida

Street Address & City (if other above)     ZIP Code
                           

Phone Number           E-mail Address
             

CLICK ON THE BOX(s)
TO SHOW WHAT YOU/ANYONE Suffer From at your residence:
Allergies         Asthma         Sinus         Fatigue         Depression

CLICK ON THE BOX(s)
FOR ALL OF THE CONDITIONS THAT ARE PRESENT:
Mold/Mildew         Pets         Snoring         Smoke         Odors         Dust        
DustMites             BadTastingWater         WaterSmells         UseAlotOfSoapToWash

Type of Residence
House         Apartment         Condo         Trailer

YOUR Residence is roughly how many square feet?

How Old is your residence approximately?

Heating Method (with ducts, fireplace, what?

Do you have A/C?(central air, window unit or none?)

Occupation

       

This is a no obligation evaluation (not a medical diagnosis)