The Pickled Beet Food Questionnaire

Build Your Menu!
Take just five minutes (yes, really!) for us to learn more about you and start building a menu to your exact goals and preferences.
INSTRUCTIONS

Please complete the following form so we can learn exactly what you like, don't like, and any food restrictions or concerns you have.

Once submitted, you will be redirected to schedule a 15-minute consultation with our head chef. Don't skip this step - we want to make sure we have all the details down to get you exactly what you want!

Our schedule books up extremely fast so be sure to book ASAP to choose your preferred date and time.

The Pickled Beet Family is looking forward to cooking for you!
Full Name*

First Name Last Name
Client Name

First Name Last Name
Date of Birth
MM.DD.YYYY
Address:*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
E-mail*
Menus will be sent to this email address for approval
Phone Number*
Is this a cell phone?*

YesNo
How did you hear about The Pickled Beet®?*

Internet SearchFriend or Family MemberFacebookInstagramOther
If Internet Search, what keywords did you search for?
Do you have any medical conditions that need to be addressed?
Ex: Diabetes, High Blood Pressure, High Cholesterol, Pregnant or Postpartum, etc
Do you have any food allergies? Please DO NOT list preferences or intolerances here. If you do not have any food allergies, write "none".*
A food allergy is an unpleasant or dangerous immune system reaction after a certain food is eaten. ex: peanuts, gluten, shellfish, eggs, etc.
Do you have any food sensitivities? Please DO NOT list preferences here. If you do not have any food sensitivities, write "none".*
A food sensitivity occurs when a person has difficulty digesting a particular food. ex: Lactose, food coloring, caffeine, etc.
Is it OK to use wine/alcohol in your meals?*

YesNoOther
Would you like Vegetarian/Vegan entrees?*

YesNoOther
What are your favorite cuisines?*

AmericanAsianCajun/CreoleCubanIndianItalianMediterraneanMexicanOther
MEATS & POULTRY
Select the types of meat and poultry that you prefer from the following list
Meats & Poultry:*

Beef (steak/roasts/ground)Bison / BuffaloLamb (chops/stew/ground/roasts)Pork (chops/roasts/ribs/ground/sausage)Veal (stew/ground/scallops)VenisonBaconChickenTurkeyDuckNoneOther
Chicken:*

BreastsThighsGroundSausageMeatloafN/AWingsOther
Turkey:*

BreastsTenderloinGroundSausageMeatloafN/A
Comments:
Ex: Only boneless chicken, no skin, etc.
SEAFOOD
Select the types of seafood that you prefer from the following list
Seafood:*

CrabShrimpLobsterSquid (Calamari)OctopusScallopsFishNoneOther
Fish:*

BarramundiBranzinoCodFlounderGrouperHalibutMahiSalmonSeabassSnapperSwordfishTunaNoneOther
Comments:
Ex: We like thin filets, no steaks, no whole fish, no skin, etc.
Non-Meat Products
Select the types of non-meat products that you prefer from the following list
Non-Meat Products:*

AmaranthBeyond Meat ProductsNutritional YeastSeitanSpeltTeffTempehTofuNoneOther
Comments:
VEGETABLES & FRUITS
Select the types of vegetables and fruits that you prefer from the following list
Vegetables and Fruits:*

Acorn SquashArtichoke HeartsArugulaAsparagusAvocadoBean SproutsButternut SquashBell PeppersBeetsBok Choy (Chinese Cabbage)BroccoliBrussel SproutsCabbageCarrotsCauliflowerCelery RootCollard GreensCornCucumbersEdamameEndiveEggplantFennelGreen BeansGreen onions/ScallionsJicamaKaleLeekLettuceMesclunMushroomsOnionsParsnipPeasPlantainsPotatoes (red/russet/gold/fingerling/peewee)RomaineShallotsSnap PeasSnow PeasSpaghetti SquashSpinachSweet PotatoesSwiss ChardTomatoesTomatillosYellow SquashYucaWater ChestnutsZucchiniOther
Comments:
Ex: Only sweet potatoes, prefer raw tomatoes, like vegetables as dente, no raw onions, etc.
Olives:*

Black OlivesGreen OlivesKalamata OlivesNoneOther
Any fruits or veggies you DO NOT like:
GLUTEN & GRAINS
Select the types of gluten and grains that you prefer from the following list
BEANS:*

Black BeansCannelliniChickpea/GarbanzoFava BeansKidney BeansLentilsPinto BeansNoneOther
GRAINS/PASTA:*

BarleyBuckwheatBulgurCouscousEgg PastaFarroGluten Free PastaMillet (Gluten Free)Oats (Gluten Free)Polenta (Gluten Free)Quinoa (Gluten Free)Rice (basmati, jasmine, white, wild, yellow) (Gluten Free)Risotto (Gluten Free)Whole Wheat PastaNoneOther
BREADS:*

BiscuitsCornbreadCorn Tortillas (Gluten Free)Flour TortillasGluten Free, Grain Free TortillasGluten Free Flour TortillasWheat BreadWhite BreadNoneOther
Comments:
NUTS & SEEDS:*

AlmondsBrazil NutsCashewChiaFlaxHazelnutHempPeanutsPecansPine NutsPistachioPumpkin SeedsSafflower SeedsSesame SeedsSunflower SeedsWalnutsNoneOther
Comments:
FLAVOR PREFERENCES
Are there any seasonings/spices that you DO NOT like?
Spice Level:*

MildSpicyVery SpicyOther
Comments:
DAIRY
Select your preferred types of dairy from the following list
DAIRY:*

Cheeses (parmesan, cheddar, swiss, blue, feta, goat, mozzarella, provolone)Regular Cheeses but Non-Dairy milkMilk (skim, 1%, 2%, whole)Cream CheeseRicottaYogurtSour CreamHeavy Cream, Half-and-HalfNoneOther
NON-DAIRY:*

Cheeses (dairy-free)Milk (almond, cashew, coconut, pea)YogurtVegan butterSour CreamGheeNoneOther
EGGS:*

WholeWhites OnlyEgg SubstituteNoneOther
Comments:
NEXT STEPS
Service Details, Billing Details & Scheduling Consultation
What type of meals are you interested in?*

BreakfastLunchDinnerDessertsSnacksSmoothiesFresh JuiceOther
Meal Schedule:*

MondayTuesdayWednesdayThursdayFridaySaturdaySundayOther
Sides:*

1 side2 SidesOther
Number of servings:*
Additional Comments
Please provide any comments, concerns, or special requests that you might have . . .
HANG IN THERE, YOU'RE ALMOST DONE!

Please complete the following billing questions. Notice that we will not be asking you for your credit card number at this moment, as we will be securely collecting that information over the phone at the end of your consultation.

Once you submit the Food Questionnaire, you will be redirected to a Calendly link where you can schedule an appointment at your convenience for a 15-minute consultation, during which you will go over your answers to the questionnaire and plan options.
Name:

First Name Last Name
Is your billing address the same as delivery address?

YesNo
Billing Address

Street Address
Street Address Line 2
City State
Zip Code Country
MEDICAL ADVICE DISCLAIMER

DISCLAIMER: THE PICKLED BEET DOES NOT PROVIDE MEDICAL ADVICE

This information, including, but not limited to, text, graphics, images, or other material contained in this form, or any communication (verbal or written) is for informational purposes only. No material on this form, or dicussion relating to it, is intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment, and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because or something you have read or discussed with any member or contractor with The Pickled Beet.
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Build Your Menu!

INSTRUCTIONS

MEATS & POULTRY

SEAFOOD

Non-Meat Products

VEGETABLES & FRUITS

GLUTEN & GRAINS

FLAVOR PREFERENCES

DAIRY

NEXT STEPS

MEDICAL ADVICE DISCLAIMER