Form

1) Full Name of Client: *

2) Address of Client:

3) Client's Phone Number: *

4) Client's Fax Number:

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

6) Type of Area (House, Apt, Office, School, etc.)

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

8) How long ago?

9) Roughly, how old is the house?

10) How many floors does the facility have? (excluding basement)

11) Is there any visual mold on the furniture and/or clothes?

12) Is there a smell in the house?

13) On a scale of 1-10 how severe is the smell?

14) What type of smell is it?

15) Where did you hear about us?

16) Why do you feel that you have amold problem?

17) Allergies symptoms described by client:

18) Which member of household is experiencing these symptoms:

19) How many members reside in the household:

20) Was a physician contacted about these symptoms

21) Is anyone in the household pregnant?

22) Did you file an insurance claim:

If Yes, Who was the adjuster?

23) Which of the floors were inspected?

24) Where did the mold come from? (Water/Sewer Damage, Seepage, etc.)

25) Are there any water lines around the sewer pit, along the beams or around the basement?

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

27) How long ago?

28) Which room was the mold found in?

29) Which floor was it on?

30) Is there carpet in the basement or hard floor?

31) Are the studs in the walls wooden or metal?

32) Outside the house, are there any cracks in the foundation?

33) How many air conditioning units are there and where are they?

34) Was there a vent system?

35) Was it also full of mold?

36) Are there windows in the basement?

37) Is a dehumidifier running in the basement?

38) Was the attic inspected?

Is there a vent?

Additional Comments:

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