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Client Request Form

FOR CLIENT USE ONLY

1) Full Name of Client:

2) Address of Client:

3) Client's Phone Number:

4) Client's Email Address:

5) Client's City:

6) Client's State:

7) Client's Zip:

8) Are you the owner, landlord, management or the tenant of the area?

9) Type of Property in Need of Mold Inspection/Remediation (House, Apt, Office, School, etc.)

10) Was there ever a flood or water damage in the house?

11) If yes, How long ago?

12) Roughly, how old is the house?

13) How many floors does the property have? (excluding basement)

14) Is there any visual mold on the walls/floors/ceiling?

15) Is there a smell throughout the property?

16) If yes, on a scale of 1-10 how severe is the smell?

17) What type of smell is it?

18) Where did you hear about us?

19) Why do you feel that you have a mold problem?

20) Allergies symptoms described by client:

21) Which member of household is experiencing these symptoms:

22) How many members reside in the household:

23) Was a physician contacted about these symptoms

24) Is anyone in the household pregnant?

25) Did you file an insurance claim:

If Yes, Who was the adjuster?

26) In what room and on which floor do you suspect mold growth?

Additional Comments:

Client Signature (by typing your name you certify that the information is correct):

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