Restaurant Allergen Disclosure Form
Customer Information
Full Name
Date
Dish Information
Menu Item
Select Known Allergens
Peanuts
Tree Nuts
Milk
Eggs
Fish
Shellfish
Soy
Wheat
Sesame
Other Allergens or Dietary Restrictions
Please specify if any
Additional Notes
Comments
I acknowledge that I have informed the restaurant staff of my allergies and understand the risk of cross-contamination.