Meal Prep Client Intake Form

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 NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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 PreferenceVegetarianVegan
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 CarbNo CarbNo BeefNo PorkNone
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:*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What meals would you like for each day?*

BreakfastLunchDinnerSnacks
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?*

MonthDayYear
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*

Clear
Type Your Full Name *
Date*

MonthDayYear
Date
Weekly Meal Payment *
prevnext( X )
Breakfast Meals
$10.00 Quantity



Lunch Meals
$10.00 Quantity



Dinner Meals
$10.00 Quantity



New Client Setup + Container DepositPlease Note: This is a one time fee.
$25.00



Delivery Fee5 Mile Radius
$10.00



Total

$0.00
Should be Empty: