FORM
Suspected Allergy/Food Intolerance Form: Operations Page 1 of 1
Effective/Review Date: 03/2021
Suspected Allergy/Food Intolerance Form
This form is to be completed when:
The parent/guardian suspects their child may be allergic to a product or has a food
intolerance;
The child does not yet have a related medical diagnosis or health care plan.
If the suspected allergy or food intolerance is medically diagnosed, a Bright Horizons Health
Care Plan, completed and signed by the child’s medical provider, is required.
__________________________________________________________________________
Child’s Name: _________________________________ Child’s Date of Birth_______________
My child has a: □ suspected allergy to: □ food intolerance to:
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
I suspect /am concerned my child may be allergic for the following reasons:
□No previous exposure □Family history □Previous reaction (please explain/date of reaction):
_______________________________________________________________________________
_______________________________________________________________________________
□Other: ________________________________________________________________________
_______________________________________________________________________________
I understand that Bright Horizons requires the most up to date information regarding my child’s
suspected allergy/food intolerance. I also understand that for the safety of my child, my child’s
photograph and allergy information will be posted in the classrooms and kitchen.
____________________________________ ___________________________
Parent/Guardian Signature Date
__________________________________________________________________________
This form must be updated annually or whenever there is any change in treatment or the
child’s condition changes. To eliminate the suspected allergy or food intolerance restriction and to
allow your child to eat the suspected item(s) while at Bright Horizons, please complete the following.
I acknowledge that my child ____________________________no longer has a suspected allergy
to and may now be served this item(s) while at Bright Horizons:
_______________________________ ________________________________
_______________________________ ________________________________
_______________________________ ________________________________
_________________________________________ ________________________________
(Signature of the Parent/Guardian) (Date)
