What Level is Your Design Business?
Full Name *
Please select any food allergies you have (check ALL that apply):DairyFishSoyShellfishEggsSesamePeanutsCornTree nutsWheat (Please do not check this for celiac disease or gluten sensitivity—only select this if you have a wheat allergy)Other
If other, please list your allergies here:
Please select any food intolerances you have (check ALL that apply):Gluten (celiac disease or non-celiac gluten sensitivity—includes wheat, barley, oats, rye)LactoseFructoseSulfitesHistaminesNitritesFructansTyramineGalactansFava BeansMSGSalicylatesPolyolsCitric acidNightshadesOther
If other, please list your intolerances here:
Please list any specific ingredients you're allergic to:
Please list other special diet needs or restrictions (e.g. Diabetes, IBS, etc.):
What are the preferred food substitutions, if any? (e.g. gluten free bread, soy milk, etc.)
What are your allergic responses?