Please complete & submit this form and prescription below
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.
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.