I HAVE LATEX ALLEGY which could include the listed accompanying allergies

Name: _____________________________________________________________________

Phone #: ____________________________________________________________________

Emergency contact Info: ________________________________________________________

If I have had an allergic reaction and have been exposed to any of the following:

Environmental Products

Foods
  • Streets that are being paved
  • Balloons
  • Rubber toys 
  • Pacifiers 
  • Rubber bands 
  • Adhesive tape and bandages
  • Diapers 
  • Condoms
  • Rubber Gloves 
  • Urinary catheters 
  • Dental materials 
  • Tourniquets
  • Poinsettias
  • bananas
  • chestnuts
  • kiwi fruit
  • avocado
  • tomato
  • figs
  • apples
  • celery
  • melons
  • potatoes
  • papayas
  • cherries
  • peaches

Please alert the attending health care practitioner of my Latex Allergy