UK NPIS 0844 892 0111
Ireland NPIC (01) 809 2566
mail@toxbase.org
  
 
A service commissioned by
Public Health England (PHE)
on behalf of the UK Health Departments
Application for TOXBASE registration

  TOXBASE on the internet is freely available to UK NHS and NHS-affiliated departments, units and practices.

Usernames are issued per unit/practice.
  Please note: By completing this form you are requesting access to TOXBASE on the internet on behalf of your unit or practice.
   
  Applications must be submitted by a senior clinician or nurse within the unit/practice, who will be asked to provide their professional registration number.
   
  Access is available to commercial companies and other users, including those overseas, by annual subscription. If you do not work for the UK NHS please submit this form to receive a subscription quotation.
   
  PLEASE TELL US ABOUT THE UNIT/PRACTICE TO BE REGISTERED
   
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?  
   
  PLEASE TELL US ABOUT YOURSELF:

Applications must be submitted by a senior clinician or nurse within the above unit/practice
   
Title:  
   
First name:  
   
Surname:  
   
Professional Registration Number:
e.g. GMC or PIN
 
   
Your job title:  
   
Your tel:
(if different from above)
   
Your fax:
(if different from above)
   
Your e-mail:   
  You must provide your NHS or work-related e-mail address
   
I confirm I am applying for TOXBASE registration on behalf of the above unit/practice
I confirm that, should I no longer be responsible for the above unit/practice, I will provide updated contact details for the new senior clinician or nurse
I confirm that TOXBASE use within the above unit/practice will be restricted to clinically trained staff
   
  PLEASE TELL US ABOUT THE HEAD OF THE ABOVE UNIT/PRACTICE
If you are the head of the above unit/practice, please provide contact details for a senior, secondary contact for your unit
   
Title:  
   
First name:  
   
Surname:  
   
Their job title:  
   
Their e-mail:   
  Please provide their NHS or work-related e-mail address
   
  PLEASE USE THIS BOX TO ENTER ANY FURTHER INFORMATION IN SUPPORT OF THIS APPLICATION
   
Where did you hear about TOXBASE?  
 
   
 
   
  If you experience problems sending this form please print and fax to 0131 242 1387