Souvenaid Connections

If you are having any difficulties in completing this form, please contact the Souvenaid Team on
1800 319 420 or at homeau@nutricia.com

About you

Who are you?*

Who will be receiving and managing communications?*

What email address shall we send communications to?*

Patient First Name*

Patient Last Name*

Carer First Name

Carer First Name*

Carer Last Name

Carer Last Name*

Preferred Telephone Number*

Additional Telephone Number

Healthcare Professional Name*

Address

Street address*

Apartment, suite, unit, etc

Suburb*

State*

Post Code*

Enrolment*

Terms and Conditions*

Terms and Conditions

I acknowledge that I have joined the Souvenaid Connections Support Program and will receive information or be contacted for the purpose of the Program.
Nutricia is required to collect personal information from you for the purposes of enrolling you to our Souvenaid Connections Program. This information may be disclosed to your healthcare professional(s) and/or carer to provide you with appropriate nutritional care.
Souvenaid has been recommended to me by a Healthcare Professional
I have read and agree to the terms of use and consent to the collection, use and disclosure of my personal information (including health information) in accordance with the Privacy Collection Notice and Nutricia’s privacy policy.
I confirm I have the authority to provide personal information (including health information) about another person

Place first order

Please tick this box if you would like help placing your first order and one of our team will call you back.

Receive Communications

I would like to receive communications from Nutricia about its products and services

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Phone

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Souvenaid® is a Food for Special Medical Purpose for the dietary management of early Alzheimer’s disease. Must be used under medical supervision.