Special — Diet Form Odsp Pdf

☐ Yes ☐ No SECTION 4: DIETARY PRESCRIPTION & MONTHLY COSTS (To be completed by prescriber) Check the applicable ODSP approved special diet components and indicate monthly estimated extra cost.

(Explain why this specific diet is medically necessary for this patient): Specific Dietary Modifications Required (e.g., gluten-free, low potassium, pureed, high-calorie supplement): Expected Duration of Diet (choose one): special diet form odsp pdf

☐ Short-term (less than 6 months – specify end date: _______________) ☐ Long-term (6+ months or permanent) ☐ Yes ☐ No SECTION 4: DIETARY PRESCRIPTION