Essential gluten-free foods request form

Name Address Postcode Phone

I have chosen the following selection of essential gluten-free foods to make up my monthly unit requirements based on the national prescribing guidelines for gluten-free foods. My monthly unit requirement is:
LOAVES & ROLLS PACK SIZE PIP CODE UNIT VALUE QUANTITY

JUVELA Gluten-Free Fresh White Loaf JUVELA Gluten-Free Fresh Fibre Loaf JUVELA Gluten-Free Fresh White Rolls JUVELA Gluten-Free Fresh Fibre Rolls JUVELA Gluten-Free White Loaf Sliced JUVELA Gluten-Free White Loaf Unsliced JUVELA Gluten-Free Fibre Loaf Sliced JUVELA Gluten-Free Fibre Loaf Unsliced JUVELA Gluten-Free White Part Baked Loaf JUVELA Gluten-Free Fibre Part Baked Loaf JUVELA Gluten-Free White Rolls JUVELA Gluten-Free Fibre Rolls JUVELA Gluten-Free White Part Baked Rolls JUVELA Gluten-Free Fibre Part Baked Rolls

8x400g 8x400g 8x5x85g 8x5x85g 400g 400g 400g 400g 400g 400g 5x85g 5x85g 5x75g 5x75g

322-0217 339-9789 355-8871 355-6800 074-8590 031-4781 074-8632 010-1675 273-6882 273-6890 010-5916 080-3668 243-7267 262-9020

8* 8* 8* 8* 1 1 1 1 1 1 1 1 1 1

ALL-PURPOSE FLOUR MIXES

JUVELA Gluten-Free White Mix JUVELA Gluten-Free Fibre Mix JUVELA Gluten-Free Harvest White Mix 500g 500g 500g 035-2161 023-6042 247-7875 2 2 2

BREAKFAST CEREALS
JUVELA Gluten-Free Flakes JUVELA Gluten-Free Fibre Flakes JUVELA Gluten-Free Pure Oats 300g 300g 500g 371-1652 371-1660 371-1678 1.5 1.5 1.5

PIZZA BASES & PASTA

JUVELA Gluten-Free Pizza Bases JUVELA Gluten-Free Fusilli (spirals) JUVELA Gluten-Free Spaghetti JUVELA Gluten-Free Macaroni JUVELA Gluten-Free Lasagne sheets JUVELA Gluten-Free Tagliatelle JUVELA Gluten-Free Fibre Penne 2x180g 500g 500g 500g 250g 250g 500g 265-4390 280-7980 280-7998 280-8004 280-7972 319-3497 332-8010 1 2 2 2 1 1 2

CRACKERS
JUVELA Gluten-Free Crispbread JUVELA Gluten-Free Savoury Biscuits JUVELA Gluten-Free Crackers 200g 150g 125g 236-6136 310-7893 377-9576 1 1 1

Gluten-free foods revised prescribing guidelines 2011 * The Juvela Fresh Loaves and Fresh Rolls are supplied in cases of 8 - this equates to 8 units of your monthly allowance

I understand that this will cover my staple needs and I can supplement this with naturally gluten-free foods and free-from foods purchased from retail outlets: Signed: