Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Are you currently:
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Do you have any allergies to fluoride or any of the constituents that make up toothpaste?
Have you had a dentist's diagnosis for dental caries, enamel demineralisation or tooth wear via erosion or increased acidity in the past 6 months and been advised to use Colgate Duraphat 5000ppm or sodium fluoride 1.1% toothpaste by a dentist?
Please advise why you are requesting treatment
I have booked or intend to have a follow up appointment with my dentist within the next 6 months.
Have you ever been informed by a healthcare professional not to use or to stop using high fluoride toothpaste such as Colgate Duraphat 5000ppm or Sodium Fluoride 1.1% toothpaste?
Do you have any open wounds or cuts inside your mouth?
Do you take any medication that causes you to suffer with dry mouth?
Are you currently using other prescribed fluoride containing products for the treatment or prevention of dental caries/tooth decay including mouthwash, oral gels or fluoride tablets?
I agree to the following:
I am aware and agree to the following:
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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