Registration | Free From Market

MEMBERSHIP SIGNUP (FREE)

The Basics
Deep Dive
Few more details
Customize
Snacks
Finish Up!

Your email is your username Minimum of 10 characters long and contain at least one uppercase and one lowercase letter (A,z), one numeric character (0-9), and one special character (such as !, %, @, or #)

What foods do you and your family avoid? (Check all that apply)*

Eggs

Shellfish

Fish

Milk/Dairy

Soy

Tree Nuts

Peanuts

Wheat/Gluten

Sesame

Other

Were you referred by your Physician?

Yes No

Did your physician write you or a family member a prescription?

Yes No

Were you referred by any of the following organizations?

Carolina FooDiversity

Blue Cross Blue Shield (BC/BS)

Stanford

Texas Children

N/A

CMH

Childrens National

Stanford GI

Lurie/Chicago

Colorado

Boston Children's Hospital

FARE

FD 2023

PIF2023

START YOUR FREE FROM JOURNEY

The Basics
Deep Dive
Few more details
Customize
Snacks
Finish Up!

Is the client a minor? Yes No

First Name: (Parent/Guardian) *

Last Name: (Parent/Guardian) *

Male Female

First Name: (Parent/Guardian)

Last Name: (Parent/Guardian)

Male Female

Client's First Name *

Client's Last Name *

Client's DOB *

Male Female

Address *

City *

State *

Zip *

County/Parish

Email Address *

Confirm Email Address *

Phone Number * Numbers only

I have prescription that I wish to upload

Family Size: How many people live in your household?*

Is the Client a veteran? Yes No

Gross household income per month $*

Gross household income per year $*

Source of Insurance Employer Provided (Name of Insurance Company) :

Market Place

Missouri Wellcare

Medicaid

Medicare

None

Race / Ethinicty

American Indian

Pacific Islander

Black or African American

Hispanic or Latino

Caucasian

Other

START YOUR FREE FROM JOURNEY

The Basics
Deep Dive
Few more details
Customize
Snacks
Finish Up!

How many members of your family have food allergies or celiac disease?

Has a doctor or other health professional ever said the client has a food allergy, celiac disease or EOE? Yes No

Has the client been diagnosed with asthma? Yes No

In the last 12 months, has a doctor or other health professional told the client he/she has asthma? Yes No

In the last 12 months, has a doctor or other health professional said the client has any of the following conditions?(Check all that apply)

Diabetes

Other Heart Condition

Cystic Fibrosis

Congenital Heart Disease

Sickle Cell Disease

Celiac Disease

Arthritis

EOE

None

In the last 12 months, how many times has the client visited the hospital, emergency room and/or doctor's office after a reaction caused by food allergy, celiac disease or EOE?

In the last 12 months, how many times has the client missed school or work after a reaction or illness by food allergy, celiac disease or EOE?

In the past 12 months, has the client seen a primary care or specialist for food allergy, celiac disease or EOE management? Yes No

During the past 12 months, did you have any trouble finding general doctor or provider who would see the client? Yes No

During the past 12 months, at any time were you unable to pay medical bills for the client due to lack of insurance coverage or lack of funds? Yes No

During the past 12 months, was there any time when the client needed any of the following, but did not get them because you could not afford it? (Check all that apply)

Prescription medication

To see a specialist

Follow-up Care

Other

None

START YOUR FREE FROM JOURNEY

The Basics
Deep Dive
Few more details
Customize
Snacks
Finish Up!

Within the past 12 months, were you worried at any point that food would run out before you got money to buy more? Yes No

In past last 12 months, did the client or parent/guardian receive any of the following services? (Check all that apply)

WIC

Speech Therapy

Head Start

SNAP

TANF

Occupational Therapy

None

In the past 12 months, have you reported the client's food allergy, celiac disease or EOE to any of the following agencies? (Check all that apply)

WIC

Head Start

SNAP

Other

School

Infant Toddler Services

None

In the last 12 months, did the client have access to the food needed to manage food allergies, celiac disease or EOE? Sometimes Yes No

In the last 12 months, were you able to afford the food needed to manage food allergies, celiac disease or EOE? Sometimes Yes No

In the last 12 months, did the client or parent/guardian receive any education/materials on how to manage food allergies, celiac disease or EOE? Yes No

In the last 12 months, did the client or parent/guardian receive any education/materials on how to read food labels to buy safe foods for the client's food allergy, celiac disease or EOE? Yes No

In the last 12 months, did the client or parent/guardian receive any education/materials on how to prepare safe foods for the client's food allergy, celiac disease or EOE? Yes No

Over the past 12 months, how confident do you feel in preparing safe meals for the client's food allergy, celiac disease or EOE?

Very Unconfident

Unconfident

Neutral

Confident

Very Confident

CUSTOMIZE YOUR SHOPPING

ALL DONE

Congratulations! Your registration has been submitted. Please be on the lookout for an approval email within 24-48 with your login information.

MEMBERSHIP SIGNUP (FREE)

START YOUR FREE FROM JOURNEY

START YOUR FREE FROM JOURNEY

START YOUR FREE FROM JOURNEY

CUSTOMIZE YOUR SHOPPING

ALL DONE

© 2023 Free From Marketplace, Inc.