Revised August 19, 2024

Food Allergy Advance Conﬁrmation Form (for restaurants)
Please understand that Hotel Nikko Alivila is a facility that is NOT able toprovide food with allergenic substances completely removed.
We would like to take this opportunity to thank you for your continued patronage. In order to ensure the safety of
our customers, we have prepared an【8-item low-allergen menu】at Brasserie “Verdemar” and Japanese Ryukyu
Cuisine “Sawa” . We would like to ask you to ﬁll out the following form with more detailed information so that wecan provide you low-allergen menu. Please understand that we will not be able to respond to any requests otherthan those made on the hotel's prescribed form.

1. Customer Information

Date of Entry

yyyy/ mm /dd

Circle either one

Name ofrepresentative

Restaurant use

yyyy /mm/dd ～ yyyy /mm/dd（

Date of stay

-Mobile Phone NumberNights）

Restaurant use

・with staywithout stay

Number of users-Name of customer
with allergies

Age*Please ﬁll out one form per person if there are more than two people with allergies.

2. Food Allergy InformationTarget Allergens
Circle your allergens

FlourEggDairy

Buckwheat Shrimp

CrabWalnutPeanuts

Other（）Symptoms
Time to reaction
Have you ever had Anaphylaxie shock?

NODo you have an EpiPen?

NO・

Yes・

Yes（Do you have yourown oral medication?

ago）
No・

Yes

※We reserve the right to refuse those with serious allergic reactions or those who have a large number of foods to be eliminated from the program.

3. Preferred response
Low allergen menu with 8 items※Reservations required at least 3 days in advancePreferred response

・Remove a portion of the food
※There is no substitution by removal

Neither of these guarantees complete elimination of allergens.

Breakfast
Restaurant Name

Date of restaurant use//()

//（)

//（)

//（)

//（)

Lunch
Restaurant Name

DinnerRestaurant NameRemarks※Please note that we limit your visit to the restaurant's opening hours. If you come outside of the opening hours, please allow 30
minutes after placing your order for your food to be served.However, this may exceed 30 minutes depending on the situation.
Continue to Food Allergy Policy

Revised August 19, 2024

Food Allergy Policy at the Hotel
We would like to take this opportunity to thank you for your continued patronage. We would like to take thisopportunity to thank you for your continued patronage of our restaurants and other facilities.

Basic Policy on Food Allergy
The kitchens of the hotel's restaurants and room service handle foods and ingredients that contain allergens such as
8 speciﬁed raw materials (ﬂour, egg, dairy, buckwheat, shrimp, crab, walnut, peanut, ) in their daily cooking
operations, and the same cooking utensils and cooking oil are used in their preparation. We use the same cooking
utensils and cooking oil for cooking. Although cooking utensils are thoroughly cleaned, there is a possibility that
small amounts of allergenic substances may be mixed into the food due to the environment of the kitchen facilities.
Therefore, we would like to inform you that we are unable to provide food that is completely free of allergenic
substances.

【Information for Customers with Food Allergies】

1、For customers with mild food allergy symptoms
・At restaurants and banquet halls that serve buﬀet-style meals, information of the 8 speciﬁed ingredients includedin the dishes is indicated on the menu card so that guests can make their own selections and prepare their ownmeals.
※Please be aware of the possibility of cross-contamination due to tongs and other utensils used by othercustomers, as well as the possibility of contamination by allergenic substances adhering to or mixing with food due
to minute residuals on scratches or other defects on dishes.
・Lounge ARIA CARA, Beach House SOL, Teppanyaki-Restaurant GOSAMARU, and Chinese Restaurant KINSHASA do
not provide individual allergy support.
2、For customers with severe food allergy symptoms
Please purchase retort pouch foods, etc. by yourself in advance and bring them with you. If you wish, we will keep
the retort pouch food you brought in and heat it up in our kitchen.
Retort pouch foods can be kept in the hotel and heated in our kitchen before serving.
※Retort pouch foods must be sealed by heat melting, pressurized and heat sterilized, and unopened.
※For food sanitation control reasons, customers are not allowed to bring in products that have been prepared orcooked by themselves.
※Please note that the hotel, in principle, discloses information on the 8 speciﬁed raw materials that are required tobe labeled, since 20 items equivalent to the speciﬁed raw materials are not required to be labeled and it issometimes diﬃcult to obtain accurate information from suppliers.
As mentioned above, due to the environment of our kitchen facilities, our ability to accommodate food allergies islimited. We will do our best to accommodate the food allergies to the best of our ability, but there may be times
when we have no choice but to refuse to provide food due to the safety of our guests being our top priority.
We ask that you make your ﬁnal decision after consulting with your own physical condition and your doctor.
If you agree to the above, please sign below.

signature

Please present two forms in advance: the Food Allergy Advance Conﬁrmation Form andFood Allergy Policy at the Hotel.
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