Placenta Encapsulation Client Intake Form {2020}
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 *
Estimated Due Date *
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DD
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YYYY
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) *
Required
Please check which services you'd like to add at an additional cost (check all that apply) *
Required
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?
Clear selection
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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