Request for Medical Waste Removal Form

Complete one of these requests for **Each Location** waste is to be picked up from.

Contact information: All fields are required.
Department:
Your Name:
Building:
Room:
Work Phone:
E-mail:

Requested for pickup Indicate the number of items for each category.
	Bags
	Sharps / Syringes

Notes

All waste requests will reply with a removal checklist attached.