Mold Information Form - We Inspect

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Step 1 of 12 - First, tell us about yourself

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First Name

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Last Name

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Email

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Phone Consent

What are you wanting to achieve by working us?*

Remediate my home so I can heal

Find out if a problem exists

Help finding a new home

Get information to pursue legal action

Do you believe your health is being impacted by mold?*

Yes

No

To your comfort level, please share any details about any symptoms or mold-related medical testing.

What size is your home?*

What type of home do you live in?*

Single Family

Apartment / Condo

Townhome

Other

Other*

Do you rent or own your home?*

Own

Rent

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does your property have any of the following features? (*Please check all that apply)*

Central Heating or Air Conditioning

Crawl space

Attic

Unfinished basement

Finished basement

None of the above

Are you aware of any water events that have impacted your home? If so, have you done anything to address it (testing, inspection, remediation)?*

What do you feel is a realistic budget range you can allocate towards your mold problem?*

This will help us determine the right service for your budget.

< $1,000

$1,000 - $5,000

$5,000 +

Phone*

phone consent

I consent to receiving SMS alerts and reminders at the phone number I provided.

*We guarantee 100% privacy. Your information will not be shared.

How did you hear about us?*

If Other*

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Practitioner Referral Code

If you were given a code by your medical practitioner enter it here.

Doctor Name*

Health Coach Name*

Which Podcast did you hear about us on?*

Which conference or webinar did you hear about us at?*

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First Name*

Last Name*

Email*

Phone*

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Do you believe mold is in your home?*

Do you believe your health is being impacted by mold?*

What are you wanting to achieve?*

What size is your home?*

Do you rent or own your home?*

How did you hear about us?*

Which Podcast did you hear about us on?*

Which Conference / Webinar did you hear about us at?*

Doctor name*

Health Coach name*

If Other*

Comments

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