Souvenaid Connections

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Souvenaid Connections

Join our growing community of patients with early Alzheimer’s disease who believe in hope. Our goal is to provide support for every patient and carer. We hope that, with our online support and our expert team, each patient can experience the clinical outcomes available with taking Souvenaid® daily.

Joining the program is FREE and includes exclusive access to the following:

Souvenaid® Facebook Community
Customer loyalty program
Expert support anytime, anywhere

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?*

Patient First Name*

Patient Last Name*

Carer First Name

Carer Last Name

Preferred Telephone Number*

Additional Telephone Number

Email Address*

Health Professional Name*

Address

Street address*

Apartment, suite, unit, etc

Suburb*

State*

Post Code*

Enrolment*

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

Terms & Conditions*

Nutricia is required to collect personal information from you for the purposes of enrolling you to our Souvenaid Connections Loyalty Program. This information may be disclosed to your healthcare professional(s) and/or carer to provide you with appropriate nutritional care. For details of how Nutricia manages your personal information, please read our Privacy Collection Notice as well as our Privacy Policy

Souvenaid has been recommended to me by a Healthcare Professional

T&C*

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

Contact*

I would like to be contacted by Nutricia for the purpose of the Souvenaid Connections Support Program

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

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Comments

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