Find a Toxicologist Directory Add/Update Form

Find a Toxicologist Directory Add/Update Form

Please use this form to manage updates for entries in ACMT's "Find a Toxicologist" Directory. This Directory has been created to serve the public and direct patients to available toxicologic treatment, as well as Medical Toxicology consultants available for medico-legal or expert witness consult and similar services.

Please fill out all lines so we may ensure the most accurate representation for your listing. If the line item does not apply to your listing please put "NA"

Posting Terms:

By posting to this directory you certify that you are an active ACMT member in good standing (dues paid), and agree to maintain the accuracy of the listing and agree to participate in an annual audit. You may also update the listing as often as needed throughout the year should there be changes.

Please fill in the information below, and acknowledge you've read and accepted the posting terms listed above.

Questions? Contact us at membership@acmt.net.

Listing Type*

Update Existing

Add New

Organization or Business Name*

Please fill in the professional or business name of the service. For example "Jane Smith, MD Toxicology Consulting Service" or "Kansas Poison Center." Do not list the name of an associated clinic, university or hospital on this line.

Address Line 1*

Address Line 2

City*

State/Region*

Country*

Zip Code*

Phone Number*

Please list the best contact phone number where patients/clients can connect to make an appointment or have questions answered.

Phone

Fax # (Optional)

Office email address (Public point of contact)*

Website*

Services Provided (List all that apply)*

Select or enter value

Physicians*

Associate Hospital/Clinic*

Please list the hospital/clinic or academic instute associated with this listing, if applicable.

Referral Preferred?*

Select

Inpatient Services?*

Select

Outpatient Services?*

Select

Directory listing contact email*

For internal use only. Will not be displayed publicly.

I have read and accept the posting terms above. *

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