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LPE Intake Form
Hello! We are so excited and honored that you have chosen LPE to serve you and your family for your placenta encapsulation needs. Please fill out this form as completely as you are able, as it will help me to ensure the best service possible.

Once this form is received, you reserve your spot with your $50 non-refundable deposit. This deposit goes towards the total cost of services, and the remaining is due upon pickup of your placenta. Upon receiving your deposit, you'll receive my Information & Instruction Packet that details all you need to know on making your postpartum period the best it can be with your placenta capsules!

If you have any questions or there are problems with this form, the best way to contact me is to call me at (308) 293-0342! I am happy to answer & definitely want to make sure you have everything you need!

Congratulations on your pregnancy! I look forward to working with you!

Kristy Pape

Lincoln Placenta Encapsulation
www.lincolnplacenta.com
P: (308) 293-0342 E: lincplacenta@gmail.com

*remaining is determined by the total cost of package(s), any travel expenses, and/or additional services
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 First Name *
Last Name *
Partner's Name
Estimated Due Date *
MM
/
DD
/
YYYY
Planned Birthing Place & Provider *
Email Address *
Phone Number *
Other Phone Numbers *
Please give any numbers that are applicable for me to contact anyone else that may assist in your birthing process, such as your partner, or someone trusted in caring for your placenta (such as a doula, friend or family member.) Please indicate who's number belongs to who. :)
Street Address *
City & Zipcode *
Allergies? *
Please list if applicable.
Blood Borne Illnesses? *
How did you hear about Lincoln Placenta Encapsulation?
Check as many as apply.
LPE Contract Statement *
I understand that this service has not been evaluated by the Food and Drug Administration. The services provided by Lincoln Placenta Encapsulation are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize these services take full responsibility of their own health for researching and using the remedies. Lincoln Placenta Encapsulation makes no guarantee as to the efficacy of the remedies, but does guarantee the highest quality of service. I release Lincoln Placenta Encapsulation and Kristy Pape and any other encapsulators contracted by Lincoln Placenta Encapsulation from any liability regarding my placenta capsules and/or tincture or any other remedy provided by her services.
What are some of the benefits you hope to receive from your placenta pills and/or tincture?
Comments and/or Questions?
Coupon or Discount Code
Other Services
On top of the basic placenta package which includes your capsules, tincture and a keepsake cord heart, I offer these additional services. Please indicate any that you would like me to provide for you. Prices are listed.
Deposit & Payment
To hold my availability, there is a non-refundable $50 dollar deposit. You can send that deposit PayPal or Venmo, but if you would like to pay it another way, please note in the comments section above; there are other options if it works better for you. Services can not be guaranteed without the deposit. Your deposit counts toward the total of your placenta encapsulation package.
May I contact you via text messaging as well as email?
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