| 1 |
You must answer this question. You must answer this question. | |
| 2 | Do you have any of the following symptoms?
- Toothache
- Tooth sensitivity, especially when eating or drinking something hot, cold, or sweet
- Grey, brown or black spots appearing on your teeth
- Bad breath
- An unpleasant taste in your mouth
You must answer this question. You must answer this question. | |
| 3 |
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| 4 |
You must answer this question. You must answer this question. | |
| 5 |
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| 6 |
You must answer this question. You must answer this question. | |
| 7 | Are you currently taking any medication (including over the counter, herbal, prescription or recreational drugs)?
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| 8 |
You must answer this question. You must answer this question. | |
| 9 | Are you aware that you can prevent some dental problems with good oral hygiene such as:
- Visitng your dentist regularly (every 6 months)
- Reducing your intake of sugary or starchy foods and drinks
- Brushing your teeth twice a day – once in the morning and once at night
- Using floss and interdental brushes in addition to normal brushing
You must answer this question. You must answer this question. | |
| 10 | Do you agree to the following?
- You will read the Patient Information Leaflet supplied with your medication
- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
- You will not drink Fluoridated water and salt while using this toothpaste
- The treatment is solely for your own use
- You are over the age of 18 and you have entered your own information for our identity verification checks
- You have answered all the above questions accurately and truthfully
- You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
- You will inform your own GP of this purchase if appropriate
- You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions
You must answer this question. You must answer this question. | |
| 11 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
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