Name

Birthdate

Phone Number

Email Address

Favorite Coffee Type

• Brewed Coffee

• Espresso

• Cappuccino

• Cold Brew

• Latte

Milk Preferences

• Whole Milk

• Almond Milk

• Oat Milk

• Skim Milk

Sweetener Preferences

• Sugar

• Honey

• Sugar-Free Syrup

Special Requests or Allergies

Please let us know if you have any special requests or allergies:

When Do You Typically Visit Our Shop?

• Morning

• Afternoon

• Evening

Are you Part of Our Loyalty Program?

How Did You Hear About Us?

• Social Media

• Online Search

• Friend/Family

Would You Like to Receive Promotions or Updates?