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Nutrition/Allergy Counseling Form
1.
Do you have any food allergies?
Yes
No
If yes, please specify
2.
Do you have dietary restrictions due to medical issues?
Yes
No
If yes, please specify
3.
Do you have dietary restrictions due to religious beliefs?
Yes
No
If yes, please specify
4.
Can Mollie, our registered dietitian, reach out to you to discuss this further?
Yes
No
If yes, please leave your name and email below