Medical Certificate Form

A Medical Certificate is written confirmation from a customer’s physician or nurse practitioner that the customer, or someone else living at the property, has a medical condition that would be aggravated if Aqua shut off the water (usually for non-payment). Once received by Aqua, a valid medical certificate gives the customer 30 days to pay the bill or to make payment arrangements.

Send your medical certificate...

By mail:
Attention: Collections Department
762 W. Lancaster Avenue
Bryn Mawr, PA 19010

By fax: 866.780.8301  

Download a certificate here

Download Aqua Ohio's Medical Certificate Form here

Download Aqua Illinois' Medical Certificate Form here

Backflow Test Form
Download Backflow Test Form

Texas Service ApplicationTX - Customer Service Agreement
TX - Customer Service Agreement (Spanish)
Click here to complete the TX application on-line via DocuSign
Haga clic aquí para completar su solicitud de TX en línea a través de DocuSign

Illinois Residential Water, Sewer Service Application Form 
Download the Illinois Water and Sewer Service Application Form

Revert to Landlord Permission

Download Revert to Landlord Permission Form