Medical Waste Disposal Request Form
Clinic Name
*
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (optional)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a Province of Manitoba Generator's Licence?
*
Yes
No
What type of Waste would you like disposed of?
*
Sharps
Blood Waste
Anatomical Waste
Amalgam Cartridge
Amalgam per KG
Dispos-a-bowl
Lead
Photo Processing Waste
Please provide # of units you would like picked up:
*
Do you need replacement sharps containers?
*
Yes
No
Submit Request
Should be Empty: