Q No.QuestionAnswer1 Have you been advised by your dentist or other healthcare professional to improve your oral health? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Do 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.Please write your explanation in the box below Yes No3 Do you agree to have regular check ups with your dentist regarding oral health and agree to report any new symptoms listed below? Tongue pain Loose teeth Jaw pain that worsens Difficulty in chewing or swallowing Red or white pathces inside the mouth You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4 Have you ever suffered from a stroke or heart attack? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5 Do you suffer, or have you ever suffered, from heart, liver or kidney problems? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6 Are you breast feeding, pregnant or likely to become pregnant any time soon? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Are you currently taking any medication (including over the counter, herbal, prescription or recreational drugs)? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8 Are you allergic to any medicines? (if you are please contact us before proceeding) You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are 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.Please write your explanation in the box below Yes No10Do 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.Please write your explanation in the box below Yes No11What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
