wELCOME TO THE FOOD ALLERGY iNSTITUTE OF NORTH TEXAS

ENJOY PEACE OF MIND
WITH OUR INNOVATIVE
FOOD ALLERGY DROP PROGRAM

fai

PLEASE COMPLETE THE FOLLOWING FORM TO FIND OUT IF YOU QUALIFY FOR THE FOOD ALLERGY DROP PROGRAM

Contact Name

Contact Number

Contact Email

Preferred Contact Method

Age of Patient

Does the patient live in the state of Texas?

Does the patient have a history of anaphylaxis?

Does the patient have asthma or eczema?

Does the patient have any suspected or diagnosed food allergies?

yes no