Gluten-Free Diet Requirement Form
Full Name
Email Address
Phone Number
Dietary Information
Diagnosis/Reason for Gluten-Free Diet
Celiac Disease
Gluten Intolerance/Sensitivity
Wheat Allergy
Personal Preference
Other
If other, please specify
How long have you been following a gluten-free diet?
Symptoms experienced if gluten is consumed
Additional Information
Other dietary restrictions or allergies
Additional notes or requirements