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 5000 ppm formulas:

Contains
Tricalcium
Phosphate
image description

PreviDent® 5000 ppm Ortho Defense

(1.1% Sodium Fluoride) Toothpaste

NDC: 0126-0289-92
Contains
Tricalcium
Phosphate
image description

PreviDent® 5000 ppm Booster Plus

(1.1% Sodium Fluoride) Toothpaste

Spearmint NDC: 0126-0074-92 Fruitastic NDC: 0126-0072-92
Booster Plus

PreviDent® 5000 ppm Sensitive

(1.1% Sodium Fluoride and 5%
Potassium Nitrate) Toothpaste

NDC: 0126-0070-61
SLS
free
Dry Mouth

PreviDent® 5000 ppm Dry Mouth

(1.1% Sodium Fluoride) Toothpaste

NDC: 0126-0016-61
Enamel Protect

PreviDent® 5000 ppm 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

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 Delaware, Florida, New Jersey, New York, Washington and Wyoming.
(Allow 4-6 weeks for delivery)