Page under construction

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
   
I confirm I am applying for TOXBASE registration on behalf of, and with the full authority of, the above named unit/practice
   
I confirm that TOXBASE use within the above unit/practice will be restricted to clinically trained staff
   
I confirm that, should I no longer be responsible for the above unit/practice, I will notify TOXBASE
   
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:
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