Omaha Placenta Encapsulation Sign-up
By submitting this form, you agree to pay the contracted amount to Mary Cleveland, of Omaha Placenta Encapsulation.
The non-refundable $50 deposit is due now, at time of sign-up, the balance is due at time of placenta pickup.
If you have questions or aren't ready to sign up yet, please contact me at omahaplacenta@gmail.com or 402-850-8603.
Thank you for your responses! They will help me to serve you quickly and efficiently!
Please make sure to press SUBMIT when you are finished with this form. Thanks!
Name & Partner's name, if applicable *
Name & Partner's name, if applicable. If your legal name on your medical chart is different than the one you go by, please note it here. Your placenta will be labeled with your legal/medical use name. Thanks!
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Email Address *
If your Paypal email is different, please include it.
Your answer
Phone Numbers *
Your answer
Address *
House number, street name, apartment number. If there are special instructions to find your home, such as it doesn't show up correctly on Google maps or you're in an apartment complex, please give detailed instructions on how to find you.
Your answer
City, State *
Your answer
Zipcode *
Your answer
Multiple babies?
Planned Place of Birth and Provider *
Hospital name, home, birth center and Doctor's or Midwife's name
Your answer
Allergies
Your answer
Do you have any Blood Borne Illnesses? *
HIV, Hepatitis, etc.
What are you hoping placenta capsules/tincture will do for you?
Your answer
How did you learn about Omaha Placenta Encapsulation?
Who may we thank? If you have a referral code, this is the place to enter it!
Your answer
I understand that this service has not been evaluated by the FDA. The services offered by Omaha 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 and for researching and using the capsules/tincture. Omaha Placenta Encapsulation makes no guarantee as to the efficacy of the capsules/tincture, but does guarantee the highest quality of service. I release Omaha Placenta Encapsulation and Mary Cleveland from any liability regarding my placenta capsules/tincture. I agree for pictures of my placenta to be used for educational/artistic purposes. *
Comments or Questions?
If you have any questions, please let me know. You can include it here, call me at (402) 850-8603 or email me at omahaplacenta@gmail.com www.omahaplacenta.webs.com
Your answer
Deposit
By submitting this form, you agree to pay the contracted amount to Mary Cleveland, of Omaha Placenta Encapsulation.
The non-refundable $50 deposit is due now, at time of sign-up, the balance is due at time of placenta pickup.
If you have questions or aren't ready to sign up yet, please contact me at omahaplacenta@gmail.com or 402-850-8603.
Thank you for your responses! They will help me to serve you quickly and efficiently!
Please make sure to press SUBMIT when you are finished with this form and go back to the website to pay deposit.
Thanks!
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