Application for TOXBASE registration

	*Please note: TOXBASE usernames and passwords are issued per unit or practice*

	PLEASE TELL US ABOUT THE UNIT/PRACTICE YOU WISH TO REGISTER:

Name of unit/practice:
	* GP users please enter name of practice here
	* Hospital users please enter name of department here

Full address:
	* Hospital users please enter name of hospital here



Town:

Postcode (or similar):

Unit/practice tel:

Unit/practice fax:

Is this unit/practice within the UK NHS / Ireland:
	If you have selected "no" to the above question please tell us about yourself and why you wish to access TOXBASE


	PLEASE TELL US ABOUT THE HEAD OF THIS UNIT/PRACTICE:
	Your unit/practice registration details will be copied to this person

Title:

Initial(s):

Surname:

Their job title:

Their e-mail:
	* Please provide an NHS or other official e-mail address

	PLEASE TELL US ABOUT YOURSELF:

Title:

Initial(s):

Surname:

Your job title:

Your tel:(if different from above)

Your fax:(if different from above)

Your e-mail:
	* Please provide an NHS or other official e-mail address

Where did you hear about TOXBASE?
	Other source:




	If you experience problems sending this form please print and fax to 0131 242 1387