This letter is to formally introduce:
Patient Name:
Date of Birth:
The above-named individual is a patient under my care and has been medically diagnosed with the following food allergy (or allergies):
Allergy/Allergies:
Due to this condition, strict avoidance and management is medically necessary. Please provide appropriate accommodations to help ensure their safety and well-being.
If you have any questions or require additional information, you may contact my office.
Physician Name:
Physician Signature:
Practice/Clinic Name:
Contact Number:
Date:
Physician Stamp (if applicable):