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Medical Form for Students with Special Dietary Needs Revised 9/14 USDA regulations require a signed medical statement from a recognized medical authority in order for the cafeteria to make substitutions for students with
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Company

Does / /

IndustryTerm

food intolerance to_________________________ / life threatening food allergy / food allergy / appropriate food selections / food allergies / food / /

MedicalCondition

allergy / food allergy / food allergies / No Food Allergies / specific food allergy / Lactose Intolerance / /

Organization

Physician Office / USDA / Authorized Medical Authority / /

Position

physician / school nurse / named physician / /

SocialTag