Food Allergy Disclosure Form
Customer Information
Full Name
Date
Allergy Details
Peanuts
Tree Nuts
Dairy
Egg
Soy
Fish
Shellfish
Wheat
Sesame
Other
If "Other," please specify:
Describe allergic reactions (optional):
Disclosure & Acknowledgement
I acknowledge that I have informed the restaurant of my food allergies, and I understand that despite efforts, cross-contact may occur.
Signature
Date