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<physician's letterhead>

Date:

RE: Medical Documentation for Travel

To Whom It May Concern:

This letter is written on behalf of my patient ____________, DOB: ___________. _________will be traveling with family from _________ to ________ and is diagnosed with a rare disorder called Food Protein-Induced Enterocolitis Syndrome (FPIES). FPIES is a severe food allergy of the gastrointestinal system that causes delayed reactions of profuse vomiting and bloody stools and may lead to hypovolemic shock. My patient must avoid all foods that cause this reaction to ensure his/her safety.

<* If patient also has an IgE-mediated food allergy, provide documentation here.>

______ currently has a limited diet and is able to tolerate the following specific foods:

<list foods here>

These foods must travel with the child at all times. If these foods are unavailable, ________ will not have any other options for his/her nutritional and dietary needs, and many of these foods are not available at <list travel destination>. I am requesting that my patient be allowed to travel with these items on board during his/her trip to <list travel destination>. It is imperative that my patient has these items as he/she will not be able to supplement them if lost.

My patient also requires:

<list medications, formula and nutritional supplements>

_______ will be traveling with large quantities of this formula/medication to maintain hydration, meet medical and nutritional needs, and avoid potential reactions.

I am requesting that my patient be allowed to travel with these items, on board, during travel to <list travel destination>. Should these items be lost, he/she will not be able to supplement them. It is imperative that my patient has this formula/medication available at all times.

_________ also requires:

<list any special accomodation patient will need for travel>

Additional information may be obtained from my office at <physician contact information>.

Respectfully signed,

PHYSICIAN'S NAME

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