Food Allergy Notification Form

Please answer the food allergy questionnaire (*indicates a required field)

The purpose of this form is to notify us of food allergies only—
it is not a survey of food preferences.
The Terrace Hotels
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Accommodation

*Hotel

*Title

Mr. Ms. Mx.

*Last Name

*First Name

*Check-in Date

/ /

*Number of Adults

*Number of Children (age 12 and under)

Contact Information

*Title

Mr. Ms. Mx.

*Last Name

*First Name

*Phone

*E-Mail

*Please check your spelling before sending.
*Please add "@terrace.co.jp" to the safe list in order to receive emails from us.

Information of person requesting hypoallergenic menu

*Title

Mr. Ms. Mx.

*Last Name

*First Name

*Birthday

*Your allergy details

Those who have been diagnosed as allergic, please let us know your allergy symptoms and doctor's supervision.

Shrimp	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil Umibudo and/or other seaweeds that may contain shrimp larvae? OK NO
Crab	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil Bivalves or umibudo and other seaweeds that may contain crab larvae? OK NG
Walnut	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil
Wheat	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil Soy Sauce Miso Cooking Sake
Buckwheat	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil
Egg	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Raw Cooked Fry Oil Mayonaisse Fish Cake or Cured Meat
Milk	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil
Peanut	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil
20 items for which labelling is not mandatory in Japan	Amond Abalone Squid Salmon Roe Orange Cashew Nut Kiwi Fruit Beef Sesame Salmon Macherel Soybean Chicken Banana Pork Macadamia Nut Peach Wild Yam Apple Gelatin
Other1	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil
Other2	Allergy reaction Sereve (may cause anaphylaxis reaction) Mild (no anaphylaxis reaction) The usage of allergens Remove completely Partial use is acceptable (Please choose the usage of allergens) Extract/Broth Binder Fry Oil

Seasoning

Are there particular seasonings that are best avoided?

If you have selected "may cause anaphylaxis reaction"

The year and month of your last reaction /

Medical Information

Those who have been diagnosed as allergic, please let us know your allergy symptoms and doctor's supervision.

Has the individual been diagnosed with any food allergies? Yes No

Has an EpiPen been prescribed? Yes No

Please describe your symptoms and details.

At our restaurants

Buffet-style meals Guest will select from the buffet items
Guest requires an allergen-free meal

Venues with no buffet Guest requires allergen-free meal
Guest will select allergen-free items from the menu

Your inquiry

Foods or dishes you customarily eat safely.

Please read the following points carefully:

With one-week advance notice, we will do our best to provide safe meals prepared without your indicated allergens from the 28 listed below.
While our chefs make every effort toward cross-contact prevention during food handling and preparation, trace levels of some allergens may be present.
Utensils and dishes used in the preparation of special meals are washed in compliance with our customary hygiene protocols.
We rely on the information provided by producers when sourcing the ingredients to meet this request.
Certain symptoms may require your provision of a medical certificate.
In the unlikely event that we are unable to prepare a meal that safely meets your allergen requirements, we will ask you to make other arrangements.
Should you require a particular food or seasonings that are not available to us locally, we may ask that you bring them with you.

I agree to all of the mentioned allergy guide

If you confirm the above, please click the "confirmation" button.

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