LPE Intake Form
Hello! I am 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 I receive this form, I will send you an invoice via PayPal for the $50 non-refundable deposit and an email to let you know that your sign-up was received and added to my calendar. This deposit goes towards the total cost of services, and the remaining $150* is due upon pickup of your placenta. Upon receiving your deposit, you'll be inboxed an 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, please contact me! I am happy to answer & definitely want to make sure you have everything you need!

Be blessed!
Madison Sasman

Lincoln Placenta Encapsulation
www.lincolnplacenta.com
402-617-0740 // lincolnplacenta@gmail.com

*remaining is determined by the total cost of package(s), any travel expenses, and/or additional services

First Name *
Your answer
Last Name *
Your answer
Partner's Name
Your answer
Estimated Due Date *
MM
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DD
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YYYY
Planned Birthing Place & Provider *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
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. :)
Your answer
Street Address *
Your answer
City & Zipcode *
Your answer
Allergies? *
Please list if applicable.
Your answer
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 Madison Sasman 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?
Your answer
Comments and/or Questions?
Your answer
Coupon or Discount Code
Your answer
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 $45 dollar deposit. You will receive a PayPal invoice for this deposit, but if you would like to pay it another way, please note in the comments 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?
Submit
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