Name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Beef

Yes

No

Lamb

Yes

No

Veal

Yes

No

Pork

Yes

No

Game

Yes

No

Rabbit

Yes

No

Poultry

Yes

No

White fish

Yes

No

Oily fish

anchovies, sardines, salmon, mackerel, tuna, etc.

Yes

No

Shrimp

Yes

No

Octopus/squid/cuttlefish

Yes

No

Mussels/clams

Yes

No