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Water Customer Medical Certification Form

Use this document to request a medical delay of water shutoff. This form must be completed by your physician, nurse practitioner, or a physician’s assistant.

Name Description Released Format
Medical Certification Form PDF This form must be completed by a physician, nurse practitioner or physician’s assistant for customers who must maintain water service due to a medical emergency. December 12, 2023
Formulario de certificación médica PDF Este formulario debe ser completado por un médico, enfermero practicante o asistente médico para clientes que deben mantener el servicio de acueductos debido a una emergencia médica. December 19, 2023

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