Food Allergy Action Plan

The Food Allergy & Anaphylaxis Emergency Care Plan, formerly the Food Allergy Action Plan, outlines recommended treatment in case of an allergic reaction. Please fill out the following with your child's information. Once the physician has reviewed it, you will receive an email to the address you list on this form with a link to print out this document.


Allergist: *

Name: *

PIN: * (This will be used to retrieve your completed document.)

Date of Birth (MM/DD/YYYY): *

Weight: * lbs.

Picture of child:

 Yes     No     If yes, high risk for severe reaction.

 Peanut        Tree Nuts        Milk        Egg        Sesame Seed        Wheat        Shellfish        Soy        Fish      

Other:

Epi Pen     AuviQ     (If your child is under 50 lbs, the junior dosage will be assigned)
Your child's physician will write in their correct Benadryl dosage

Comments:

Parent / Guardian Name:*

Email Address:*

  By checking this box, you are agreeing that the above information is accurate and to
submit this information to a physician dated 01/23/2019.