Placenta Client Intake Form and Contract

Intake and Contract

1Contact and Pregnancy Information > 2Health and Allergy Information > 3Preparation Methods and Add-ons > 4Limitations and Disclaimer > 5Review Your Entry > 6Payment
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Birthing Parent's Name Birthing Parent's Name First Last
Birthing Parent's cell phone Birthing Parent's cell phone - ### - ### ####
Birthing Parent's email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Additional Contact Person (usually the partner) Additional Contact Person (usually the partner) First Last
Additional Contact's Cell Phone Additional Contact's Cell Phone - ### - ### ####
Has your baby been born yet?

Has your baby been born yet? Yes - Please contact me ASAP to make pickup arrangements No - I'm still pregnant!
Please tell my how your placenta was stored after your birth.

PLEASE NOTE: If your placenta was not on ice, in a refrigerator, or frozen within TWO HOURS after your birth, it is not usable. If your placenta has been on ice or refrigerated for MORE THAN 48 HOURS after your birth, it is not usable. If your placenta was frozen within 48 hours after your birth, it can be encapsulated.
Estimated Due Date Estimated Due Date / MM / DD YYYY
Planned place of birth (home, hospital, birthing center)
Please choose your birthing facility

Please choose your birthing facility AAMC Family Health and Birth Center GWUH Holy Cross Germantown Holy Cross Silver Spring Home Howard County General INOVA Alexandria SGAH Sibley Walter Reed WHC Other Other
Will this be your first birth?

Will this be your first birth? No Yes
Which Placenta Arts Package are you choosing?

Which Placenta Arts Package are you choosing? Delight ($325) Bliss ($360) Rapture ($415) Sweetness ($150) - includes choice of one add-on services and cord keepsake. Capsules and smoothie drops cannot be included with this package)
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Placenta Client Intake Form and Contract

Placenta Client Intake Form and Contract

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