Revised August 19, 2024

Food Allergy Advance Conﬁrmation Form (for weddings and general banquets)
Please understand that Hotel Nikko Alivila is a facility that is NOT able toprovide food with allergenic substances completely removed.

The purpose of this Preliminary Conﬁrmation Form is to ensure the safety and security of our customers. Please ﬁllout the following form to provide us with detailed information about your stay.
Please understand that we will not be able to respond to any requests other than those made on the hotel's
designated form.
If you wish to use the “Allergy Menu,” please submit it at least 3 weeks prior to the date of your stay.

1. Customer Information

Date of Entry

yyyy/ mm /dd

Circle either one

Name ofrepresentative

Restaurant use
with stayyyyy /mm/dd

Date of reservation-Mobile Phone Number

・Restaurant use
without stay-

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 Information
Target Allergens
Circle your allergens

Flour

EggDairy

Buckwheat Shrimp

CrabWalnut

Peanuts

Other（）Symptoms
Time to reaction
Have you ever had Anaphylaxie shock?
Do you have an EpiPen?

NONO・

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
No menu changes
requined →Preferred response
Menu change
requined →You can eat
All dishes as they are・

You can take and eat
food at your own decision

Remove a portionof the food・

Need analternative dish※No substitution by removal
Neither of these guarantees complete elimination of allergens.

4. Target Cuisine
Name of dish5. OtherContinue 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.
The following is our hotel's policy for guests with food allergies.

Basic Policy on Food Allergy
IThe kitchens of the hotel's restaurants and room service handle foods and ingredients that contain allergens suchas 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 allergenicsubstances.
Information for guests with food allergies
1. For guests with mild food allergy symptoms(1) In the case of buﬀet dishes: Information on the 8 speciﬁed raw materials included in the dishes is indicated on
the menu card.Please choose by yourself.
Because of buﬀet style please be aware of the possibility of cross-contamination by tongs and other utensils
used by other customers, as well as contamination by allergenic substances that may adhere to or be mixed in withthe food due to minute residues on dishes and other surfaces.
(2) For course meals: Please consult with us.
(3) For table service: Not available.
2、Customers with severe food allergies
Please purchase retort pouch foods, etc. by yourself in advance and bring them in. If you wish, you can bring yourown retort pouch food, etc.
Retort pouch foods can be kept in the hotel and heated in our kitchen before being served.
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 or
cooked by themselves.
Please note that, in principle, the hotel discloses information on the 8 speciﬁed raw materials that are required to belabeled, since 20 items equivalent to the speciﬁed raw materials are not required to be labeled and it is sometimes
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. However, we place the utmost priority on the safety of our guests, and there may be times when wehave no choice but to refuse to serve a dish.
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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