SMS Meal Service Form Name* First Last Email Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pets NamesHome PhoneCell PhoneDo you have children at home? Yes No Number of children (if applicable) Children's namesDo you have any pets?* Yes No If yes, are they indoor or outdoor pets? Indoor Outdoor Do any family members have food allergies?* Yes No if yes, please explain what they are allergic to (i.e.seafood, gluten, peanuts, etc.)Is anyone lactose intolerant?* Yes No Are you requesting Vegan or Vegetarian meals? (please not there is an additional cost for speciality meals.)* Yes No Are you on a weight-loss program? (please note there is an additional cost for special diets) South Beach Atkins Paleo Dash Are there any dietary restrictions? High blood pressure No salt Low fat Low carbohydrates Are you requesting organic for all menu items? (please note there is an additional cost for organic)* Yes No CommentsDo you require portion control for your meals?* Yes No Are you sensitive to any of the following: Garlic Onions Mushrooms Bell peppers Tomatoes Other Sensitives:Your spicy food scale Bland Mild Medium Hot Does your selection represent all family members that SMS will be cooking for?May we cook with wine or other liquors?* Yes No What fruits and vegetables do you dislike?*What fruits and vegetables do you like?*When you eat out, what restaurants do you frequent?*What cuisines do you enjoy? Mexican Italian French Thai Chinese Other?How many times a week do you eat beef?*Please enter a number from 0 to 7.How many times a week do you eat pork?*Please enter a number from 0 to 7.How many times a week do you eat chicken?*Please enter a number from 0 to 7.How many times a week do you eat turkey?*Please enter a number from 0 to 7.How many times a week do you eat fish/seafood?*Please enter a number from 0 to 7.Fish/Seafood FavoritesWhat spices/herbs do you not like?*Overall favorite dishes*Other comments:CAPTCHA
