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 or Ireland?

	If 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?




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