Placenta Services Order Form

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Hello! My name is Nicole and I am a midwife who performs placenta services in the Tampa Bay area. If you are interested in making a purchase, fill out the form below and I will gladly complete your request.

Each order comes with an umbilical cord keepsake and directions for use.

If you have questions or concerns, please reach out!

Nicole Whiting

(224) 600-3064

nicolewhiting226@yahoo.com

IG: @nicolethequeermidwife

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Name *

Phone Number *

I will text you to coordinate pick up/delivery and to check in after a couple weeks of consumption.

Where are you planning to have your baby? *

Home, Birth Center (specify), Hospital (specify)

When is baby due? *

AAAA

What is the item you would like to order? Select all that apply. *

Other products may be available upon request. Please specify in the box and I will contact you about availability and cost.

Placenta pills ($200)

Tincture ($75)

Placenta print ($25) - please write desired colors in the 'special information' box

Altro:

Obbligatorio

Preferred payment method (payment is due upon delivery of product) *

Cash/Check

Venmo (@newhiting)

Paypal (nicolewhiting226@yahoo.com)

Cashapp ($newhiting)

Zelle (224-600-3064)

Any special information I should know? *

Baby's name (depending on length, can be incorporated into cord keepsake), specific pattern you'd like the cord keepsake to be, desired colors for the placenta print, etc.

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