Food allergies
and intolerances

Customer Name: ____________________
Date: ________________________________
Table Number: _______________________
‍
Allergy / Intolerance Information
Please list any food allergies, intolerances, or dietary requirements:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Customer Declaration
I confirm that I have informed the restaurant of my food allergy(ies), intolerance(s), and/or dietary requirements.

I understand that while every reasonable precaution is taken to prevent cross-contamination, all food is prepared in a kitchen where allergens are present, and
therefore a completely allergen-free environment cannot be guaranteed.

I have discussed my dietary requirements with a member of staff and understand the allergen information provided regarding my meal choices.

I acknowledge and accept the potential risk of cross-contamination despite the restaurant’s best efforts to minimize this risk.

Restaurant Confirmation

Staff Member Name: _________________
Dietary requirements communicated to the kitchen: ☐Yes ☐No
Manager/Supervisor informed (if required): ☐Yes ☐No

Additional Notes:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Signatures
Customer Signature: ________________
Date: _______________________________
Staff Signature: _____________________
Date: _______________________________

Important Notice
We take food allergies and intolerances extremely seriously and follow strict procedures to reduce the risk of cross-contamination. However, due to the nature of our kitchen operations and shared preparation areas, we cannot guarantee that any dish is completely free from allergens.

Please inform a member of staff of any allergies, intolerances, or dietary requirements before placing your order. Thank you for helping us ensure your safety and enjoyment.