Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Date of Birth
MM
DD
YYYY
Complete Address
*
City
*
How did you hear about Carte Blanche Culinary?
If Internet Search, what keywords did you search for?
Do you have any medical conditions that need to be addressed?
*
Ex: Diabetes, High Blood Pressure, High Cholesterol, Pregnant or Postpartum, etc
Do you have any FOOD ALLERGIES? Please DO NOT list preferences or intolerances here. If you do not have any food allergies, write "none".
*
A food allergy is an unpleasant or dangerous immune system reaction after a certain food is eaten. ex: peanuts, gluten, shellfish, eggs, etc.
Do you have any FOOD SENSITIVITIES? Please DO NOT list preferences here. If you do not have any food sensitivities, write "none".
*
A food sensitivity occurs when a person has difficulty digesting a particular food. ex: Lactose, food coloring, caffeine, etc.
Is it OK to use wine/alcohol in your meals?
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Yes
No
Would you like Vegetarian/Vegan entrees?
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Yes
No
What are your favorite cuisines?
*
Please check all that apply.
Meats & Poultry I do not want:
*
Please check all that apply.
Chicken cuts I do not want:
*
Please check all that apply.
Turkey cuts I do not want:
*
Please check all that apply.
Seafood I do not want:
*
Please check all that apply.
Fish I do not want:
*
Please check all that apply.
Non-meat Products I would like to INCLUDE in my meals:
*
Vegetables and Fruits I do NOT want:
*
Please check all that apply.
Comments
BEANS I do not want:
*
Please check all that apply.
GRAINS/PASTA I do not want:
*
Please check all that apply.
BREADS I do not want:
*
Please check all that apply.
Comments
NUTS & SEEDS I do not want:
*
Please check all that apply.
Comments
Are there any seasonings/spices that you DO NOT like?
Preferred Spice Level:
*
Mild
Spicy
Very Spicey
Other
Comments
DAIRY items I do not want:
*
Please check all that apply.
NON-DAIRY items I do not want:
*
Please check all that apply.
EGGS I do not want:
*
Please check all that apply.
Comments
What type of meals are you interested in?
*
Meal Schedule
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Sides
*
1 Side Dish
2 Sides
Other
Number of Servings
1
2
3
4
5
6
7
8
9
10
