Dental

About Your Health

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Have you undergone a tooth decay, enamel demineralization, or tooth wear examination by your dentist in the last 6 months?

Yes

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?

Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Planning on Becoming Pregnant

Neither Pregnant nor Breastfeeding

What is your biological gender?

Please select your option

Male

Female

Date of Birth

Use the calendar to select your date of birth.

Do you experience sensitivity to fluoride or any of the other components in toothpaste?

Yes

Have you used any other fluoride-containing products, such as mouthwash, for the same purpose lately?

Yes

Do you have a history of using Colgate® Duraphat®?

Yes

Are you on any medications that cause you to have dry mouth?
If you do, please explain which drug is causing these side effects and how serious they are.

Are there any wounds, injuries or open cuts in your mouth?

Yes

Do any of the following symptoms apply to you:
Toothache
Sensitivity of the teeth, particularly when eating or drinking something hot, cold, or sweet
Spots on your teeth that are grey, brown, or black

Yes

Do you visit your dentist every six months for a checkup?

Yes

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Yes

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