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Personal Information
Name
*
First Name
Last Name
E-mail
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Work Phone Number
Number of Adults in Household
Number of Children in Household (optional)
Children's Ages (optional)
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Service Options
Service Package
*
Fresh Convenience Package
Fresh Premiere Package
Meals Per Delivery
Delivery Frequency
*
Weekly
Bi-Weekly
Monthly
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Health Information
Medical Information (check all that apply)
Diabetes
High Blood Pressure
High Cholesterol
Crone’s Disease
Celiac Disease
Gluten Intolerance
Lactose Intolerance
Pregnant
Bariatric Patient
Other
Allergies (check all that apply)
Peanuts
Tree Nuts
Wheat/Gluten
Shellfish
Other
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Dietary Preferences
Dietary Preferences
FDA Standard Recommended Diet
Low Fat
Low Sodium
Low Carbohydrate
Low Sugar
High Protein
High Fiber
Other
Vegetarian?
No
Pescatarian (no meats but will eat fish)
Flexitarian/Semi-Vegetarian (mostly vegetarian but sometimes meat)
Lacto-Ovo-Vegetarian (no meat, fish or shellfish but will eat dairy and eggs)
Lacto-Vegetarian (no meat, shellfish, fish or eggs but will eat dairy)
Ovo-Vegetarian (no meat, shellfish, fish or dairy but will eat eggs)
Vegan (no meat, fish, poultry, eggs, dairy, honey)
Other
Meat/Poultry/Seafood (check all you do NOT eat)
Beef, Sirloin, Chuck, Steaks, etc.
Ground Beef
Bone In Chicken
Boneless, Skinless Chicken Breast
Boneless, Skinless Chicken Thigh
Ground Chicken
Chicken Sausage
Turkey
Ground Turkey
Turkey Sausage
Pork
Salmon
Cod
White Fish
Tuna (fresh and canned)
Mahi Mahi
Shrimp
Other
Vegetables (check all you do NOT eat)
Red, Yellow and Orange Bell Peppers
Green Bell Peppers
Broccoli
Carrots
Cauliflower
Celery
Cucumber
Eggplant
Garlic
Green Beans
Hot Peppers
Kale/Greens
Lettuce
Mushrooms
Onions/green onions/shallots
Peas/Snow/Snap Peas
Potatoes
Spinach
Sweet Potatoes
Tomato
Winter Squash-Acorn, Butternut, etc.
Summer Squash-Zucchini, Yellow Squash
Other
Starch & Legumes (check all you do NOT eat)
Brown Rice
Wild Rices
Quinoa and other Ancient Grains
Lentils
Chick Peas (Garbanzo Beans)
Black Beans
White Beans
Pinto Beans
Conventional Pasta
Whole Wheat Pasta
Gluten Free Pasta
Other
Cuisines (check all you do NOT eat)
Classic American
Southern American
Mexican
Italian
Greek/Mediterranean
Indian
Chinese
Thai
Cajun
Other
Spice Preference
1
2
3
4
5
Cold
Hot
1 is Cold, 5 is Hot
Any other foods you or a family member will NOT eat?
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Delivery Options
Meal Delivery Preferences (generally we deliver directly to your refrigerator)
*
I will provide a key
I will provide a garage door code or opener
I will provide a security alarm code
I prefer delivery outside my door. I will provide and place a very large cooler or two medium size coolers outside of my residence door. I understand that, especially during the summer months, the food in the coolers should be collected in no more than 3 hours. Delivery generally occurs mid-afternoon. I understand that 5th Avenue Fresh LLC cannot take responsibility for food spoilage when delivery takes place outside of the residence.
Other
How did you hear about us?
Referral
Hire-a-Chef Website
Internet Search
Other
Referral name so we can thank them
Who do you think would benefit from our personal chef services?
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