Name Email Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip/Postal Code Phone Number How did you hear about us? - Select -Google searchSocial media (Facebook, Instagram, etc)ReferralShowroomBest Picks ReportsHouzzHome AdvisorAngie's ListManufacturer/VendorLBK Work TruckHouse & Home MagOther... Who referred you? How many people live in your household? - None -12345678910 How many bathrooms do you currently have? - None -1234567 How many master bathrooms? - None -1234 How many full bathrooms? - None -1234567 How many 1/2 bathrooms? - None -1234567 How long do you plan on staying in this home? - None -1 - 5 years5 -10 years10 or more yearsOther... What about your current bath situation prompted you to set this appointment? Does the room need to be ADA Compliant? - None -YesNoMaybe How long have you been contemplating a bath remodel? - None -1- 5 years5 - 10 years10 or more years Are there any other home improvement projects that you are considering? Current Bathroom Please select all that apply. Bath options Tub Tub/Shower Combo Acrylic Steel Cast Iron Corner Tub Platform Tub Free-Standing Walk-In Whirlpool/Jacuzzi With Jets Without Jets Shower options Shower Stall Acrylic Tile Other Barrier free shower Half wall Shower entry Shower Door Curtain Rod-Straight Crescent Lavatory Toilet Urinal Bidet Options Light Bar Sconces Exhaust Fan/Light Heat Lamp Linen Closet Grab Bar(s) Toilet Paper Holder Open Shelving Hand-Held Shower Head Towel Bar(s) Robe Hook(s) Medicine Cabinets - None -1234 Mirrors - None -1234 Flooring - None -TileVinylOther... Walls - None -PaintTileOther... Are there windows? Where are they located? Must-Haves For New Bathroom Please select all that apply. Bath options Tub Tub/Shower Combo Acrylic Steel Cast Iron Corner Tub Platform Tub Free-Standing Walk-In Whirlpool/Jacuzzi With Jets Without Jets Shower options Shower Stall Acrylic Tile Other Barrier free shower Half wall Shower entry Shower Door Curtain Rod-Straight Crescent Lavatory options Toilet Urinal Bidet Options Light Bar Sconces Exhaust Fan/Light Heat Lamp Linen Closet Grab Bar(s) Toilet Paper Holder Open Shelving Hand-Held Shower Head Towel Bar(s) Robe Hook(s) Rain Shower Head Tiled Niche in Shower Recessed Shelving in Shower Do you want you bathroom to be a place of relaxation ? Do you want to incorporate laundry into space? Do you want to expand bathroom? Do you want a towel warmer? - None -YesNoMaybe Do you want heated floors? - None -YesNoMaybe Styling Your style Favorite color Favorite fixture finish Tub/Shower Surround/Base Preference Current Issues Please select all that apply. Problem areas - None -LeaksDamagesMold/MildewDifficult to cleanLimited spaceOdd layoutWater pressure Tiles popping from - None -WallsFloor Wish List All of your wish list What budget do you have in mind for your bathroom? - Select -$28,000 - $40,000$40,000 - $50,000$50,000 - $60,000$60,000 - $75,000$75,000 - $10,000$100,000 - $150,000Budget not listed When do you plan to begin your project? When do you want to have your project completed?
