Contract & Order Form
Form must be completed and payment made to reserve service.
Email address *
Your name *
Your answer
Estimated due date *
MM
/
DD
/
YYYY
Phone number *
Your answer
Address *
Your answer
Intended place of birth *
Required
Special instructions or requests
Your answer
Preparation Method *
Required
Capsules *
Tincture (organic alcohol)
Placenta art
Payments *
Please add up your total and send it to https://paypal.me/orplacenta
Required
Is there anything else?
Your answer
Signature (name and birth date) *
Your answer
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