Placenta Services 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
Your answer
Bloodborne Pathogens at TIme of Birth *
Required
Placenta Preferences
Encapsulation Method *
Capsule Type *
Please choose the capsule you would like me to use.
Add On Services
$30 for one, $50 for two
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
Please note that if you are booking at 2 weeks of less time until your estimated due date, the full fee is due at signing.
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 $50.00 is due upon contract signing via Paypal. If Quincey is present, cash/check is acceptable. This $50 is put toward your total bill.
Method of Payment *
Mileage (ONLY for clients outside of Whatcom County)
Please select if you would like pick-up, drop-off, or both. I will pick-up and deliver for the fee listed below, as far south as Mount Vernon. Please contact me for further information.
I would like....
Shipping and Handling
This will apply to any clients who choose to have their capsules shipped to them and we have agreed upon this arrangement ahead of time. Amount will be added to invoice.
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.

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.
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