(e.g., gluten-free, low potassium, pureed, high-calorie supplement):
You can download the Special Diet Allowance Form (ODSP-IS-221) in PDF format from the Ontario government's website or from the ODSP website. special diet form odsp pdf
| Diet Component | Check if required | Monthly Additional Cost ($) | |----------------|------------------|-----------------------------| | Gluten-free | ☐ | $ ______ | | Low Lactose / Lactose-free | ☐ | $ ______ | | Low Sodium (≤1500mg/day) | ☐ | $ ______ | | Low Potassium (Renal) | ☐ | $ ______ | | Low Phosphorus (Renal) | ☐ | $ ______ | | Pureed (Dysphagia) | ☐ | $ ______ | | Liquid / Supplemental (e.g., Ensure, Boost) | ☐ | $ ______ | | High Protein / High Calorie | ☐ | $ ______ | | PKU / Metabolic formula | ☐ | $ ______ | | Other (specify): __________ | ☐ | $ ______ | Registered Dietitians
Physicians registered with the College of Physicians and Surgeons of Ontario. Registered Nurse Practitioners (Extended Class). Registered Dietitians. special diet form odsp pdf