Medical Dietary Restrictions Form

Medical Dietary Restrictions Form

This form is for medical restrictions to diet only. Once completed, your submission will be reviewed by the management team. Please contact the lodge manager and chef for any questions or concerns regarding the menu.
Select your site*
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please select all that describe you:

I have food allergiesCeliac/Gluten IntoleranceLactose IntolerantDiabeticCholesterol Restrictions
Food Allergies:

Peanut ProductsFish/ShellfishEggsSoy productsMilkTree nuts (Walnuts, almonds, pecans etc.)GlutenSulphitesMustardOther
Please give additional detail about your diet here:
Supporting Documents:

If you have any doctors notes, allergy test results or other supporting documents please include them here.
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Should be Empty: