Healthcare Food Contact Declaration

Healthcare Food Contact Declaration

Patient Information

Date of Birth:    Gender:

Phone:    Emergency Contact:    Emergency Phone:

Insurance Information

Food Contact Details

Please indicate the nature of the food contact (select all that apply):

Food brought by patient     Received from visitor     Hospital provided

Date of contact:    Time:    Location within facility:

Source/Packaging:

Was the food commercially prepared?    Yes    No     Was temperature control maintained?    Yes    No

Allergen Disclosure

Known allergens present in the food items (check all that apply):

Milk    Eggs    Peanuts    Tree nuts

Soy    Wheat    Fish    Shellfish

Sesame    Other:

Medical History Relevant to Food Contact

Declaration, Consent and Liability Acknowledgment

I, the undersigned, declare that the information provided in this Healthcare Food Contact Declaration is true and complete to the best of my knowledge. I understand that accurate disclosure of food contents, source, preparation, and allergens is material to my clinical care and to the safety of other patients.

I authorize the facility and its clinical staff to examine the described food item(s) and to communicate this information to the treating care team, dietitian, and pharmacy as necessary to manage medical risk. I authorize facility staff to retain, refrigerate, or dispose of the food item(s) as required by facility policy for patient safety.

I acknowledge that the facility may refuse to accept or permit consumption of outside food that does not meet safety or dietary requirements. I release the facility and its employees from liability for adverse reactions resulting from undisclosed allergens or from consumption of food items contrary to medical advice, except to the extent caused by gross negligence or willful misconduct of the facility.

I agree to indemnify and hold harmless the facility from claims arising from my failure to disclose ingredients, food sources, or prior adverse reactions. This release does not limit the facility's obligations under applicable law to provide emergency care in the event of a reaction.

HIPAA/Privacy Acknowledgment: By signing below I consent to the disclosure of the food contact details and related clinical information to personnel involved in my care for the purpose of assessing and managing risk associated with food exposure. I understand that such disclosures are limited to information necessary for my treatment and safety.

I acknowledge that I have read and understand this declaration, and that I may withdraw this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Signature

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