Dental Care Form / Dental Care / Oral Care / Browse Categories | Goodcure

Are you between the ages of 18 and 55? *

Yes
No

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? *

Yes
No

Have you been recommended to use high fluoride toothpaste by a UK registered Dentist? *

Yes
No

Are you aware of the duration of use and dosage instructions? *

Yes
No

Are you currently using any other prescribed fluoride containing products for the same use including a mouthwash? *

Yes
No

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

Yes
No

Do you have any open wounds or cuts inside the mouth? *

Yes
No

Do you intend to have a recall appointment booked with your dentist within the next 6 months? *

Yes
No

Please list any other conditions (if any) that you have been diagnosed with.

Please list any prescribed medicines, supplements or herbal preparations? (This includes treatments for unrelated conditions, treatments bought over the counter, inhalers, recreational drugs, creams etc.

Please list any allergies and intolerances that you suffer from (if any) below.

In the field below, please include any other information you would like to provide which you think may be useful for our prescriber (Optional).

First Name *

Last Name *

Date of Birth *

Street Address *

Town/ City *

Post Code *

Contact Number *

Email Address *

Name of Registered GP surgery *

GP Surgery Street Address *

GP Surgery Postcode *

Click on the links below to access the terms and conditions, and the privacy policy. Please ensure that you have read them carefully.

Goodcure Pharmacy Terms and Conditions

Goodcure Pharmacy Privacy Policy

I have understood and agree to the Goodcure Pharmacy's terms and conditions as well as the Privacy Policy
This treatment is solely for my own use
I understand that if I experience any flu-like symptoms after returning from my trip for up to a year after I return, I should seek immediate medical attention and tell the doctor about my background and recent travel history
I consent to my details, including IP address, being securely processed and cross-checked by Stripe Radar® for fraud and misuse prevention, as well as Didit® for identity and age verification.
I confirm that all the information that I have provided is correct and accurate to the best of my knowledge. I understand that prescribers take my answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to my health. I understand that Goodcure Pharmacy cannot be held responsible for any harm whatsoever resulting from inaccurate information provided my myself.
I agree to read the product information leaflet carefully and ensure that I understand it well before using any product or treatment provided by Goodcure.
I agree that should I experience any adverse effects resulting from treatment or products obtained from Goodcure Pharmacy, I will discontinue the treatment immediately and seek medical advice as soon as possible.
I am aware that Goodcure Pharmacy, in accordance to their professional and moral duty, may report any cases where misuse of treatments or the illegal selling of treatments is suspected.

Please tick the box below to confirm that you understand and agree to the above important points: *

I understand and agree to all of the above

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