Treasured Birth Services - Belly Binding Client Contract
Please complete this form to reserve belly binding services. I will be in touch with you within 24 hours of receiving your completed form to confirm booking and discuss payment.
Full Name *
Your answer
Email *
Your answer
Phone *
Your answer
Home/Street Address *
Your answer
Estimated Delivery Date/Birthing Date *
MM
/
DD
/
YYYY
Which package would you like to purchase? *
I serve all areas within 25 miles of Ogden, Utah. If you are outside this radius, there is an additional charge of $1 per mile.
Pant size (before pregnancy) *
Would you like the optional warming paste? *
Ingredients include: turmeric, bentonite clay, black pepper, cloves, ginger, cinnamon, and calendula.
As your Belly Binder, I will:

- Provide you with a new wrap
- Come to your home and bind you
- Teach you how to continue binding yourself
- Discuss a self-care plan for the newborn stage
- Provide services within 7 days of delivery
- Provide an herbal salve, upon advanced request, for no additional cost
Please initial to show that you have read and understand your belly binders responsibilities as listed above. *
Your answer
I ask that you:
- Please try and schedule your Belly Binding services around 37- 40 weeks gestation. This allows enough time for your bind to be made, and for me to ensure you are booked in my schedule.

- Understand that services will be completed at the agreed upon time. If for some reason, timing needs to change, we will arrange another mutually agreed upon time.

- Understand that unforeseen circumstances (i.e. family emergency, illness, weather, acts of God) does not negate services. I will make all attempts to provide you with appropriate services.

- Provide payment via cash/check or paypal, prior to date of services. Payment is final and may not be refunded unless I, Hanan Webster, default on the contract, or a medical reason permits you from being bind.

- Disclose any illnesses, physical complications or concerns prior to service.

Please initial to show that you have read and understand the above statement about your responsibilities. *
Your answer
Disclaimer
As a non­-clinical support person, I make no medical claims for the outcomes of my services. I cannot guarantee results, but the binding is most effective when wrap is worn for 8­-12 hours daily for about 40 days. The mother should be released from the care of her doctor or midwife before beginning belly binding; mothers who have delivered by cesarean should wait until their stitches have been removed. I am in no way responsible for confirming release with your care provider; this is your personal responsibility.

Please notify me before beginning if you have any particular medical concerns, or allergies to any products that I may be using (including turmeric, cinnamon, ginger, nutmeg, coconut, avocado.) Because I am not a licensed herbalist or medical professional, I am not to be held responsible for any medical decisions made ­- my sole purpose is to provide for the physical comfort and emotional support of the postpartum mother.

Your wrap should be worn as much as possible during the first 6-8 weeks postpartum. For best results: take a warm shower before binding or applying paste. Be sure to drink plenty of water and/or herbal tea.

Please type your name as your signature to complete your contract for services. Thank you! *
I the undersigned agree to save Treasured Birth Services/Hanan Webster harmless from any and all liability, liens, claims, demands, damages, expenses, fees, costs, fines, penalties, suits, proceedings, actions and causes of action of any and every kind and nature arising or growing out of or in any way connected with participation in BELLY BINDING. Treasured Birth Services/Hanan Webster does not give medical advice and you agree to consult a doctor or midwife before making any medical decisions in regards to the use of Belly Binding.
Your answer
How did you hear about Treasured Birth Services? *
If referred by someone specifically, who can I thank?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service