1
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?

NoYes

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?

NoYes

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:

Kidney problems,
Hormone or sugar problems?(e.g. diabetes, thyroid problems),
Neurological problems?(e.g. parkinsons, previous stroke or mini-stroke).
Liver problems?(e.g. hepatitis, fatty liver, alcohol liver disease),
Breathing problems?(e.g. asthma, COPD, bronchiectasis),
Mental health problems?(e.g. anxiety, depression, personality disorder) or
Thyroidectomy (removal of thyroid)
Or any other diagnosed conditions.

NoYes

Please provide more details

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

NoYes

Please provide more detail.

Do you have any allergies to medications or any other substances?

NoYes

Please list everything you are allergic to and what symptoms you experience.

Do you take or use any recreational drugs?

NoYes

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?

NoYes

Please provide more detail.

2
Medical Questions

Do you have any allergies to fluoride or any of the constituents that make up toothpaste?

NoYes

Please provide more details

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?

NoYes

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.

Confirm

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?

NoYes

Please provide more details

Do you have any open wounds or cuts inside your mouth?

NoYes

Please provide more details

Do you take any medication that causes you to suffer with dry mouth?

NoYes

Please provide more details

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?

NoYes

Please provide more details

I agree to the following:

I will use the toothpaste to brush for approximately 3 minutes, three times a day after meals and not rinse afterwards
I will contact Cloud Pharmacy and inform my dentist of my toothpaste if I experience any side effects of treatment or if my medical conditions change during treatment
I will have routine monitoring of my dental health by my dentist whilst using Colgate Duraphat 5000ppm or sodium fluoride 1.1% toothpaste through our service
I understand that the toothpaste is not meant for ingestion and only for use within the mouth
I will avoid intake of excessive salt whilst using this toothpaste

Confirm

I am aware and agree to the following:

Colgate Duraphat and Sodium Fluoride 1.1% toothpaste should only be used on real teeth and is not suitable to clean dentures
That I can prevent some dental problems with good oral hygiene including; reducing my intake of sugary foods and drinks, using floss and inter-dental brushes in addition to normal brushing and visiting my dentist regularly

Confirm

3
Consent

Would you like us to notify your GP of the treatment you chose to order today?

NoYes

Please provide details.

Doctor Surgeries

[% doctor_surgery.practice_name %]

No Results found

Searching

I can't find my surgery and would like to edit the address below.

Please enter your GP details below

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:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via LexisNexis
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

NoYes

Sorry we can't offer you this treatment, please contact your GP.

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.

Assessment

Trust Pilot

Medical Questions

2
Medical Questions

3
Consent

Doctor Surgeries

No Results found

Searching

Confirm treatment selection

Useful links

Information

Customer care

External Links

Here to help

Assessment

Trust Pilot

Medical Questions

2Medical Questions

3Consent

Doctor Surgeries

No Results found

Searching

Confirm treatment selection

2
Medical Questions

3
Consent