Placenta Encapsulation Client Intake Form {2018}
We're so glad you've chosen us to encapsulate your placenta. So that the specialists of Embrace After Birth may place you on their calendar and be "on call" for you, please complete the form below and send a $50 non-refundable deposit via Paypal to info@embraceafterbirth.com.
Name *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Birth Location *
Baby # *
Home Address *
(please include any special instructions on where to park or how to enter the home)
Your answer
Please check which services you'd like, in addition to capsules (at no additional cost to you): *
Do you or anyone you live with smoke inside the home? *
Have you been diagnosed with HIV or Hepatitis C? *
Do you have any questions or anything you wish to share?
Your answer
How did you learn about Embrace After Birth?
Phone Number *
Your answer
E-mail Address *
Your answer
Please indicate your agreement with the following statement: "I understand that I am responsible for transporting my placenta to the destination in which it will be encapsulated. I also understand that if my placenta is sent to the hospital's pathology lab that that renders it not suitable for encapsulation." *
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