Home Delivery
Application Form

Please complete & submit this form and prescription below
OR
Send the original form and prescription to PO Box 202 HAMPTON VIC 3188

All details provided on this page, including personal and credit card details are transferred directly to Cortex and are not stored on the website. 

All details are kept securely by Cortex and our partner pharmacy in order to facilitate your prescription order.

Personal Information
Medicare Details
test
Delivery Details
Your Prescriber (doctor’s or dietitian’s) information
Credit Card details
Payment Authorisation

I authorise Cortex Health to retain my prescription repeats and to provide my details to their nominated pharmacy for the purposes of dispensing my prescription and deducting any copayment required for each prescription from my credit card

Upload Prescription

PLEASE NOTE: Your ORIGINAL PRESCRIPTION must be sent with this application

Cortex Health will retain the customer’s prescription repeats to allow for efficient processing and delivery.

All personal information collected will be securely stored in accordance with the Privacy Act 1988 (Cth). To view your records or for further information please contact CORTEX Health Pty Ltd, 85 Argus Street, Cheltenham, VIC 3192 or call 1800 FOR PKU or fax 1800 678 713.

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