Assisted Living Menu Form

Assisted Living Menu Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Facility Name
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select one option
How many residents do you have at your facility?
Do you Facility require any special dietary provisions? If yes, please specify (ex. low carb, low sodium, mechanical soft, etc.
What is the age and gender distribution of the population?
Please upload your menu here (word document preferred)

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By signing below, I understand the following:
- This menu was created using guidelines provided by reputable organizations including but not limited to the Maryland DHMH Diet Manual for Long-Term Care Residents, the United States Department of Agriculture (USDA), Food and Drug Administration (FDA), Academy of Nutrition and Dietetics (AND), the American Diabetes Association (ADA), and the American Heart Association (AHA).
- This menu and each nutrient analysis are reviewed by a dietitian that is credentialed with the Commission on Dietetic Registration (CDR) and licensed in the state of Maryland to practice dietetics by the State Board of Dietetic Practice through the Maryland Department of Health.
- Based on the menu and recipes listed, the dietitian certifies that the menu is sufficient to provide adequate nutrition to meet the Dietary Reference Intakes (DRI) for macro- and micronutrients for adults. If a menu item or receipe changes, we cannot guarantee that the nutrient analysis would remain accurate.
- Payment for the menu is due upfront, and all sales are final.
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Date

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Date
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