Placenta Intake Form
The Birth Servant
When is your due date or estimated day of baby's arrival?
Where will the birth take place and pick up location be (I can do pick up as soon as 2-3 hours after birth)?
What is your phone number(s) so I can add you to my contacts? Please add in my phone number to text or call at (802)-280-5706.
Where will I be dropping off placenta goods (it takes approximately 24-48 hours to finish dehydration and capsule process)?
Which placenta services are you interested in (click all that apply)?
Cord burning kit - $10
Lotus birth kit - $40
Burying placenta - free; only asking for gas money
Raw smoothie(s) - $15
Dehydrated capsules with Traditional Chinese Method - $175
Dehydrated capsules with Raw Method - $150
Tincture in 100 proof alcohol - $20
Print (please specify how you want it printed) - $15
Dehydrated cord keepsake (please specify shape or wording preferred) - $5
Do you understand I am a student midwife and may be on call or at another birth at the time of your delivery/drop off time and will be of service as soon as I am available (or my back up can begin the process)?
Yes, that is fine
No, I will be finding another placenta specialist
Options for payment (I send invoices through Square or Paypal)
Pay non-refundable $25 deposit at 36 weeks pregnant and remainder of fee due by 4 weeks postpartum
Pay full invoice at 36 weeks pregnant
I am looking for a sliding scale option
Payment plan option (customizable)
I have a coupon gifted by The Birth Servant, Alisha Stoltzfus
Send me a copy of my responses.
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