Organic Birth Placenta Services Contract
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Your Due Date *
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Your Name: *
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Your Partners Name:
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Your Telephone Number: *
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Your Partner's Telephone Number:
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Your Email Address: *
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Your Partner's Email Address:
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Your Home Address: *
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Birth Location and Address: *
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Midwife/Gynaecologist name and number: *
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Doula or other birth attendant name and number:
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Have you encapsulated in the past *
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Sex of baby: *
Vegan/Vegetarian: *
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Allergies (e.g. Latex) *
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How did you hear about Organic Birth placenta remedies? *
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Why have you chosen to use placenta remedies for your postpartum health? *
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Please select the remedies you wish to purchase: *
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