Enrolment Form

  • 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
  • Who are you ? *
  • Patient First Name *
  • Patient Last Name *
  • Carer First Name
  • Carer Last Name
  • Preferred Telephone Number *
  • Additional Telephone Number
  • Email Address *
  • Healthcare Professional Name *
  • Street address *
  • Apartment, suite, unit, etc
  • Suburb *
  • State *
  • Post Code*
  • Country *
  • first order
  • call back
  • Enrolment*
  • 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

  • Terms & Conditions *

If you are having any difficulties in completing this form, please contact the Souvenaid Customer Care team at 1800 884 367 or nccl@nutricia.com