Dietary Preferences Survey

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Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

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Email* This field is required.

example@example.com

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Birthday* This field is required.You must be 18 or older

Date

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Gender* This field is required.

Male

Female

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How many times a day do you eat?* This field is required.

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Please select the diet that most closely matches your food choices:* This field is required.

Vegan: includes plant-based foods only and excludes animal foods of any kind.

Vegetarian: includes eggs, milk, milk products and plant foods, but excludes red meat, fish and poultry.

Standard: includes red meat, fish, poultry, eggs, milk, milk products and plant foods.

Pescetarian: includes fish, eggs, milk, milk products and plant foods, but excludes red meat and poultry.

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Please provide any additional details not covered above:

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Favorite Meal Options & Restaurants (for breakfast, lunch, snacks):

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AppointmentBook some time with Gerniah

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Book a time with Chef Don