Patient Forms

Pre-registration form: Please download and complete the following form and bring it with you on your first visit.

The Banner – University Medicine Toxicology Clinic provides non-emergent services to patients, with a referral from a physician, in an outpatient setting for the following conditions:

  • Environmental exposures
  • Work injury/exposure
  • Adverse drug effects
  • Drug interactions
  • Venomous bites
  • Heavy metals
  • Interpretation of laboratory results
  • Independent medical evaluations

For emergencies, call 911. You can also call the Banner Poison and Drug Information Center hotline at (800) 222-1222, available 24-hours a day, 7 days a week including holidays.

Inpatient Care is provided at Banner – University Medical Center Phoenix and younger patients may be admitted to a local children’s hospital. Inpatient care requires a referral from a physician.

Outpatient/Clinic Care - All patients served by the Banner – University Medicine Toxicology Clinic require a referral from a physician for out-patient services.

Please note: The Medical Toxicology Referral Form must be completed by referring provider.

Banner Health and University of Arizona Health Network have come together to form Banner – University Medicine, a health system anchored in Phoenix and Tucson that makes the highest level of care accessible to Arizona residents.

Banner – University Medicine includes Banner – University Medical Center Phoenix, Banner – University Medical Center Tucson and Banner – University Medical Center South, Banner Children’s at Diamond Children’s Medical Center, the University of Arizona Cancer Center, physician clinics and a health plan division.

Across its campuses Banner – University Medicine performs life-changing research and provides graduate medical education to those who go on to touch lives across Arizona, the nation and the world. The medical centers are a vital part of Banner Health’s mission to make health care easier, so life can be better.

Academic Medicine Difference

The partnership between Banner Health and the University of Arizona brings clinical care delivery, education and research to the forefront of the patient experience.