Placenta Encapsulation Client Intake Form {2021}
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.
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Name *
Estimated Due Date *
Email Address *
Phone Number *
Birth Location *
Home Address *
Please list any special instructions on where to park, how to enter the home or anything else we may need to know
Please check which services you'd like, in addition to capsules (at no additional cost to you) *
Please check which services you'd like to add at an additional cost (check all that apply) *
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?
How did you learn about Embrace After Birth?
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Baby number *
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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