Colgate

Welcome to the Colgate® Prescription Pad Request Site Did you know that pharmacies may dispense alternative high-fluoride toothpastes? Did you know that you can ensure your prescription is dispensed as prescribed? Here's how: Write/Check the NDC code for one of the following five unique patented Liquid Gel 5000ppm formulas: NOW AVAILABLE PreviDent® 5000ppm Kids (1.1% Sodium Fluoride) Toothpaste NDC: 0126-0311-92 ContainsTricalciumPhosphate PreviDent® 5000ppm Ortho Defense (1.1% Sodium Fluoride) Toothpaste NDC: 0126-0289-92 ContainsTricalciumPhosphate PreviDent® 5000ppm Booster Plus (1.1% Sodium Fluoride) Toothpaste Spearmint NDC: 0126-0074-92 Fruitastic NDC: 0126-0072-92 PreviDent® 5000ppm Sensitive (1.1% Sodium Fluoride and 5% Potassium Nitrate) Toothpaste NDC: 0126-0070-61 SLSfree PreviDent® 5000ppm Dry Mouth (1.1% Sodium Fluoride) Toothpaste NDC: 0126-0016-61 PreviDent® 5000ppm Enamel Protect (1.1% Sodium Fluoride and 5% Potassium Nitrate) Toothpaste NDC: 0126-0022-92 Mark Dispense as Written (DAW), Brand Necessary, or your state-mandated equivalent Order your Rx pad today at colgateprevident5000.com Designate number of refills Click here for full prescribing information. If you prefer to dispense PreviDent® 5000 in your practice, click here to order Colgate® PreviDent® 5000 FREE Prescription Pad Request Form Fields marked with * are mandatory. Based on state requirements we are no longer able to provide Rx Pads to California, Delaware, Florida, New Jersey, New York, Washington and Wyoming. *Full Name: *License Number: *Practice Address: Select State Alabama Alaska Arizona Arkansas Colorado Connecticut District of Columbia Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia West Virginia Wisconsin *Email: *Practice Telephone: *PreviDent Kids Pads: 0 1 2 3 4 *Booster Plus, Sensitive, Dry Mouth and Enamel Protect Pads: 0 1 2 3 4 *Booster Plus Pads: 0 1 2 3 4 *Sensitive Pads: 0 1 2 3 4 *Dry Mouth Pads: 0 1 2 3 4 *Enamel Protect Pads: 0 1 2 3 4 *Ortho Defense Pads: 0 1 2 3 4 Submit your request (Allow 2-3 weeks for delivery)