Hazardous Waste Form

Your Details

Your Full Name

Your Company Name

Home Address Including Post Code

Your Mobile Number

Site Details

Site Contact Name and Details (This should be a person who is based at the premises concerned)

Site Contact Details (Full Name)

Site Address for collection and delivery

Clinic Site Telephone number

Please leave instructions for how to locate the sharps boxes, ie Please ask for Mandy, they will be in the store cupboard in reception. Or please ask for James - they will be in the physio room .

Please call to let me know when someone is on their way for collection

Yes No

If yes, Which phone number

Clinic Site Number Personal Mobile Number

Can you please state the days and times that you are at the premises and a contact number for you. Please note that we try to collect and deliver around 10 workings days after we have received your signed Docusign Form. If you are not available Monday to Friday - then it may take longer than 10 working days to coincide your collection with us having a collection rep in your area.

If you require sharps boxes collecting please List the size and quantity of each type

Please state the number and size of boxes that you would like delivering:

1L Bin - qty

2.5L Bin - qty

5L Bin - qty

7L Bin - qty

11.5L Bin - qty

Orange bags - qty

Type of Business

(please tick to confirm) and go to Customer Declaration
I confirm all the waste collected is from a non-medical activity and therefore non-hazardous, consignment Notes don’t apply. (Please note Cytotoxic/static & Dental waste is always hazardous and you require a different form)

What is your Association Membership Number? (Must be completed) - You can find your membership ID number here

Date

I have read and understand the next steps:
Thank you for your form. This will be reviewed and a Docusign Form will be emailed to you within 3 working days at the address that you have entered above. This will be from Docusign. Please check your spam and junk. Once the form is received, your collection will aim to take place within 10 working days. (except if you are not available for collection all 5 days of the week - in which case - it may take longer as we can arrange for when one of our representatives is in your area). Please contact us on 08000 66 55 52 (enter number 3 for customer services) if you have any questions. Please try to be available around the 10 working days after the form has been returned as you have stated in the form to ensure collection.

Apologies but at this time we cannot accept any sharps disposal orders. As you may or may not know our partner Citrone Hygiene has been bought out by PHS but we were given no notice of the change. PHS has also taken so long to try and help us with our orders and after speaking to three different departments PHS are not able to provide the service we require.

We are trying to arrange an alternative supplier and although we do not expect this to take too long, at the same time this will not be up and ready in the next couple of weeks. We suggest temporarily that you purchase a 1 litre box which you can hand in for free to any community chemist or pharmacy once full.

We will of course keep you up to date with the service.