Healthcare waste collection referral form

Entries marked with * are mandatory.

We will only use the personal information collected on this form for the purposes of reassessing the healthcare waste collection. The information will only be kept on file for as long as is necessary.

Patient's Details

Enter the name, address and telephone number of the person who requires the collection.

Patient's name *

Patient's address (including postcode) *

Patient’s telephone number *

Patient's email address

Proof of Medical Condition

For us to provide you with a second black bin we need to have proof of your medical condition(s), and evidence that this produces additional waste that cannot be recycled. This can be provided to us by uploading a photograph or scan of the letter from a doctor or hospital confirming the medical condition and additional waste details.

If you have any queries regarding the proof needed, please don’t hesitate to contact us on 0115 901 3621.

Please upload the scan or photograph of your letter from the doctor or hospital *

Please confirm the medical condition *

Healthcare professional's name

Healthcare professional's position

Organisation name

Healthcare professional's contact address (including postcode)

Healthcare professional's telephone number

Healthcare professional's email address

Contact Details

Please confirm the details of the relevant person to contact should there be any queries with this form.

Contact's name *

Contact's address (including postcode) *

Contact's telephone number *

Contact's email address *

Contact's relationship to patient *

Conditions

We are not able to collect waste contaminated with cytotoxic or cytostatic medication.

If you have any queries please don’t hesitate to contact us on 0115 901 3621.

I declare that I have read the conditions above and the information that I have provided on this form is true and accurate *

I declare

Data Protection

We will use the information provided by you to provide waste collection services. The basis under which the Council uses personal data for this purpose is that this is necessary for the performance of a task carried out in the public interest by the Council or in the exercise of official authority vested in the Council.

The information provided by you includes the following special categories of personal data, health. Information in these categories is used by the Council on the basis that you have given explicit consent and in accordance with the provisions of the Data Protection Act 2018.

The Data Controller is Gedling Borough Council, Civic Centre, Arnot Hill Park, Arnold, Nottingham, NG5 6LU. You can contact the data protection officer at the above address or by email at dataprotectionofficer@gedling.gov.uk

The information provided by you may also be used for the purpose of any other function carried out by the Council. Information about these functions and further information including how long we retain your data, who we share with and your rights can be found in our privacy notice.