In-Take Form Name(Required)Email(Required) PhoneDate of Birth MM slash DD slash YYYY Gender Female Male Address Street Address Address Line 2 City State 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 ZIP Code Meal Prep Goals | Check all that applyChoice 1 Eat Healthier Choice 2 Lose Weight Choice 3 Gain Weight Choice 4 Gain Muscle Weight Meal Plans | Single serving portions; choose number and type of mealsMeals are $13 + tax each plus delivery with discounts for repeat customers.Choice 1 8 Meal Plan Choice 2 10 Meal Plan Choice 3 14 Meal Plan Choice 4 Custom LunchLunchLunchLunchDinnerDinnerDinnerDinnerAllergies/Special InstructionsMeal Plan PreferencesAre you following a food plan?Are you following a food plan? Yes No If yes, what food plan are you following?Rate desired FAT intake: Low Medium High Rate desired SALT intake: Low Medium High Is it okay to use ALCOHOL in your food? Yes No Taste PreferencesSpicy Dishes: Little to None Mild Medium Hot VegetablesA Artichoke Asparagus Beet Root Bell Peppers Bok Choy Broccoli Florets Brussel Sprouts Butternut Squash B Cabbage Carrots Cauliflower Celery Corn Cucumber Eggplant C Green Beans Lettuce Mushrooms Onion Okra Peas Potatoes D Radishes Spaghetti Squash Spinach Tomato Turnips Yellow Squash Zucchini Fruits (Seasonal)A Apples Apricots Avocado Bananas Blackberries Blueberries Cantaloupes B Cherries Cranberries Grapes Grapefruit Guava Honeydew Melon C Kiwi Lemon Lime Mango Nectarines Oranges D Peaches Pears Pineapple Raspberries Strawberries Watermelon ProteinsChicken Chicken Turkey Turkey Beef Beef Pork Pork Plant Based Meats Plant Based Meats Shrimp Shrimp FishFish A Tilapia Fish B Grouper Fish C Salmon Fish D Mahi Mahi Fish F Cod Fish E Snapper Fish G Flounder Starches (Brown rice & whole wheat pasta are used if available or requested)Starch A Potatoes Starch B Pasta Starch C Rice LegumesLegumes A Black Beans Legumes B Black-eyed Peas Legumes C Kidney Beans SoupsSoup A Turkey Chili Soup B Cabbage & Carrots Please include any additional information or special requests:Congratulations and thank you for taking this step to incorporate Custom Fit Meal Prep as a lifestyle choice to improve your overall health. After reviewing your responses, Chef Steve will be contacting you to schedule a start date for your custom meals. Deadline for ordering meals or to cancel an order is Wednesday at noon.Date submitted MM slash DD slash YYYY
