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Medical Waste Patient Certification Form

City of Kawartha Lakes
Public Works Department
PO Box 9000, 26 Francis St
Lindsay, Ontario K9V 5R8
705-324-9411 extension 2360
Fax:705-328-3122

Name of Patient:

Patient's Address:

City/Town/Village:

Province:

Postal Code:

This document certifies that the Patient named above requires extra waste collection as a result of medical homecare treatment at the address identified above.

The City requires confirmation of homecare by a health care provider to assure compliance before the expanded collection will be approved.

Name of Healthcare Professional (please print):

Address for Healthcare Professional:

City/Town/Village:

Province:

Postal Code:

Telephone:

Signature of Healthcare Professional:

Date:

The service being requested includes:

Add the Patient to the "Medical Waste Register" and receive garbage bag tags for medical waste collection (excess of the two (2) bag limit.

Send additional garbage bag tags to the address indicated above (already on the register; healthcare professional signature is not required beyond the initial request).

Remove the Patient from the "Medical Waste Register"

Signature of the Patient or their Representing Family Member:

Telephone Number:

Name of Representing Family Member:

Relationship to Patient:

Please submit the completed form to:

Kayla Pantaleo, Regulatory Compliance Officer
Solid Waste Division, City of Kawartha Lakes
PO Box 9000, 322 Kent Street West
Lindsay, Ontario K9V 4T7

Fax: 705-324-3122

Personal information contained on this form is collected pursuant to the Municipal Act, 2001 and will be used for the purpose of responding to your request. Questions about the collection of this information should be directed to the City Clerk or Deputy Clerk at clerks@kawarthalakes.ca.

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Medical Waste Patient Certification Form

This document certifies that the Patient named above requires extra waste collection as a result of medical homecare treatment at the address identified above.

The City requires confirmation of homecare by a health care provider to assure compliance before the expanded collection will be approved.

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