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H2O Applied Technologies
Feasibility Forms

PRELIMINARY ASSESSMENT

Using the information you provide below, we will send you an
estimate of what a Utility Expense Reduction Program at your
healthcare organization would include.

Submitted by:
 
First Name*
Last Name*
Title*
Email*
Phone
Fax
Please send my
assessment via: 		Email   Fax   US Mail
Facility Information:
 
Facility Name*
Address 1*
Address 2
City*
State*
ZIP
# of Beds
# of Full Time Employees
# of Outpatients/Year
Approx. Square Footage
Utility Information - Annual $$ Spent On:
 
Water/Sewer
Electricity
Gas/Oil
Medical Waste
Solid Waste
Telecom
Comments
* = Required field