Placenta Truffles Contract
Thank you for your interest in my placenta services! This form also serves as your contract, so please fill in as thoroughly as possible. If you do not receive a response from me within 48 hours, please call 360-820-2439 or email quincey@doulaq.com. I look forward to working with you!
Client Questionnaire
Estimated Due Date *
MM
/
DD
/
YYYY
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Phone Number *
Your answer
Birth Location Address *
Please specify whether the location is Home, Hospital, or Birthing Center
Your answer
Home Address *
Please enter the address you'd like your capsules/other product delivered to
Your answer
Do you have any allergies? *
If you answer "yes", please list below
If you answered yes to the question above, please list your allergies here (Please note! Truffles are made in a kitchen where allergens may be present)
Your answer
Placenta Preferences
Truffle Flavors *
$225 for 1 flavor included. $8 for each additional flavor
Required
Umbilical Cord *
Placenta Print *
Amazing prints of your placenta made on acid free paper. Can be printed with the a non-toxic paint, or with the fluids already on the placenta (this may not last as long and could fade).
Payment Options
Deposit for Services *
To ensure that your due date and 28 day window (14 days before and 14 days after) is kept in my calendar, a $75.00 is due upon contract signing via Paypal. If Quincey is present, cash/check is acceptable. This $ is put toward your total bill.
Method of Payment *
Mileage
This will apply to any clients whose pickup and/or drop off locations are outside the Whatcom County. Amount will be added to invoice.

Pickup and drop off: $20.00 each, as far as Anacortes. Please contact me for addition information.

Important Information
IMPORTANT! Ensure that your care provider knows that you want to keep the ENTIRE placenta.

Please read and place a check mark by EACH item, ensuring me that you read and understand all that is laid out for you. Contact me if you have any questions.

Shipping and Handling
This will apply to any clients who choose to have their truffles shipped to them and we have agreed upon this arrangement ahead of time. Amount will be added to invoice.
Checkbox *
Required
Disclaimer
The information on this page has not been evaluated by the Food and Drug Administration. These services I offer are not clinical, pharmaceutical or intended to diagnose or treat any condition. Families who choose to utilize the services I provide, take full responsibility for using the remedies at their own risk.
Expiration of Fees
All fees are subject to change. Once the form is submitted, you will not be subject to increasing prices. However, once this form is sent to you, fees are good for 30 days after receiving.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service