Food Allergies and Sensitivities

Food Allergies and Sensitivities Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Please choose your allergy/ies from the list below *

Fish Shellfish Tree Nuts Peanuts Dairy Eggs Soy Wheat

Other, please explain *

How severe is your allergy? *

What triggers your allergy? E.g. ingestion, inhaling, contact, etc. *

Do you wear a medic alert bracelet? *

Yes No

Do you carry an epi pen? *

Yes No

Is there anything else we should know about your allergy? *

Submit

901 Eden Road . Lancaster, PA 17601