Hounslow home patient collection request form

Home patient clinical waste collection requests on behalf of the London Borough of Hounslow
  • REFERRER DETAILS

  • Please enter your six digit account number, for example 900001
  • DD/MM/YYYY
  • Please provide a direct email address, to allow us to clarify any information provided in this form.
  • HOME PATIENT CONTACT DETAILS

  • HOME PATIENT COLLECTION DETAILS

    It is important to provide the correct information to ensure we have the correct paperwork, and provide the correct receptacles on collection.
  • Please enter the number of bags the patient requires.
  • Please enter the number of sharps units the patient requires.
    Please select the frequency of collections from the checklist menu.
  • Please enter the week commencing date to allow us to schedule an appropriate collection date.
    Please select yes or no.
  • Please let us know where the waste will be located to enable our driver to locate the waste on arrival.
  • Please use this box to let us know any special requirements that we should take into account.
  • This field is for validation purposes and should be left unchanged.