Application for TOXBASE online registration

TOXBASE online accounts are issued per unit/practice

~ by completing this form you are requesting access to TOXBASE online on behalf of your unit/practice

~ applications must be submitted by a senior clinician or manager

~ applicants will become the Account Holder, who will have responsibility to:
- relay login details to clinical colleagues and validate the unit/practice account by email annually
- receive other emails and letters related to management and activity of the Account

Applicants are advised to review our Terms and Conditions and Data Protection Notice

Those who do not wish to take on the role of Account Holder may register for individual access via the TOXBASE app for iOS and Android (self-registration is done within the app)

If you do not work for the UK NHS you can find further information here and a subscription quotation request form.

NHS AND NHS-AFFILIATED USERS
Please complete the form below to request an account for your unit or practice

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):

Is this unit/practice within the UK NHS?

	PLEASE TELL US ABOUT YOURSELF: Applications must be submitted by a senior clinician or manager within the above unit/practice

Title:

First name:

Surname:

Your job title:

Your organisation:	Full name of your organisation, e.g. "NHS Lothian"

Your e-mail:
	You must provide your NHS or work-related e-mail address

Select to confirm	I confirm I am applying for TOXBASE registration on behalf of, and with the full authority of, the above named unit/practice
Select to confirm	I confirm that TOXBASE use within the above unit/practice will be restricted to clinically trained staff
Select to confirm	I confirm that, should I no longer be responsible for the above unit/practice, I will notify TOXBASE
Select to confirm	I confirm I am happy for my contact details to be held on file by the NPIS for use in relation to management of the Account
	If you would additionally like to opt in to receive news of research, interesting cases or other clinical toxicology-related items by email please let us know by confirming below:
Select to confirm	I confirm that I would be happy to receive occasional newsletters or other information regarding clinical toxicology/poisoning by email Your information will never be sold or shared

	PLEASE USE THIS BOX TO ENTER ANY FURTHER INFORMATION IN SUPPORT OF THIS APPLICATION


Where did you hear about TOXBASE?




	On submission your application will be considered by NPIS Edinburgh, which is based within and operated through NHS Lothian. NPIS Edinburgh is the NPIS unit responsible for administering and editing TOXBASE. Applicants can expect to receive an email response within 1-2 working days (M-F, 9am-5pm). If you experience problems sending this form please print and and scan to mail@toxbase.org

Cookie on TOXBASE®

TOXBASE online accounts are issued per unit/practice