Request A Quote

Facility Information

Facility Name*

Street Address*

City / State / Zip*

Contact Name*

Email Address*

Phone Number*

Facility Type*:

HospitalClinicSurgery CenterDental OfficeNursing Home / Long-Term CareLaboratory / Testing FacilityVeterinaryFuneral and Cremation ServicesSchool: Primary or SecondarySchool: College or UniversitySalon/Body Art FacilityOther

If Other, please specify:

WASTE TYPE & VOLUME

Please choose the type of waste generated* (check all that apply):
Red Bag (Regulated Medical Waste)SharpsPathologicalChemotherapy WastePharmaceutical WasteHazardous Waste

How many containers do you normally have for pickup or anticipate having?*

PICKUP & SERVICE PREFERENCES

Preferred pickup frequency*:
WeeklyBi-WeeklyMonthlyEvery Six MonthsOn-Call / As NeededOther

If Other, please specify:

Days/Times Available for Pickup:*

CURRENT SERVICE PROVIDER (Optional)

Do you currently have a waste service provider?
YesNo

Provider Name:

Contract Expiration Date:

Why are you considering switching?

FOLLOW-UP

Preferred contact method*:
EmailPhoneText

When do you need service to start?*

Additional Comments or Notes: