Meal Prep Client Intake Form
Thank you for selecting Chefene's Culinary Creations for your meal prep services. Please complete the form below.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Meal Preferences
Please indicate the type of meals you are interested in for your plan.
*
Organic ($2.00 Additional)
Pescatarian ($2.00 Additional Fee)
Regular/No Preference
Vegetarian
Vegan
Please indicate any fruits/vegetables you wish to avoid:
*
Type "N/A" if none
Please indicate any meats or seafood you wish to avoid:
*
Type "N/A" if none.
Please indicate any flavors or spices you wish to avoid:
*
Type "N/A" if none.
Please indicate any food or dietary restrictions:
*
Type "N/A' if none.
Any additional food preferences?
*
Low Carb
No Carb
No Beef
No Pork
None
Favorites
Please indicate favorite dishes/foods below.
Favorite Food/Dish #1
*
Type "N/A" if none.
Favorite Food/Dish #2
*
Type "N/A" if none.
Favorite Food/Dish #3
*
Type "N/A" if none.
Meal Program Details
Meals are $10.00 per meal and $5.00 per snack unless otherwise indicated or special dietary selections are made by the client.
Indicate the days of the week you would like meals:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What meals would you like for each day?
*
Breakfast
Lunch
Dinner
Snacks
How many Breakfast meals per week?
*
Type "0" if none.
How many Lunch meals per week?
*
Type "0" if none.
How many Snacks per week?
*
Type "0" if none.
How many Dinners per week?
*
Type "0" if none.
What date are you looking to begin you meal prep?
*
-
Month
-
Day
Year
Date
Please indicate any other helpful food information you would like to share:
Disclaimer & Signature
Consult with your physician before beginning any nutrition plan. The information and food provided is in no way intended to replace any medically supervised program, physical diagnosis or prescription medication. Chef Steph has been educated and trained in the proper handling of foods and storage and utilizes those practices to ensure that your food will be an enjoyable safe product. However, once Chef Steph has completed service and delivered food, you are responsible for continuing proper food storage and handling techniques to prevent food-borne illness. If you have any questions concerning proper handling techniques, I will be happy to discuss them with you. Please feel free to contact Chef Steph at any time with any questions or concerns you may have regarding your meals. I look forward to working with you and serving your needs in the best possible way. By signing below, I fully understand that I am to consult with a medical physician before beginning any nutrition plan or discontinuing any medically supervised program or prescribed medications. I am also aware that Chef Steph (M. Stephene P. M. Johnson) is an educated, trained and ServSafe Certified (#7885156) chef and is not liable for food-borne illness.
Signature
*
Type Your Full Name
*
Date
*
-
Month
-
Day
Year
Date
Weekly Meal Payment
*
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Breakfast Meals
$10.00
$
10.00
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Lunch Meals
$10.00
$
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Dinner Meals
$10.00
$
10.00
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New Client Setup + Container Deposit
Please Note: This is a one time fee.
$25.00
$
25.00
Delivery Fee
5 Mile Radius
$10.00
$
10.00
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