Client Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Client Intake Form

Thank you for choosing Afterbirth Anywhere for your placenta encapsulation services. We look forward to helping you improve your postpartum experience. In order to provide you with the best possible services, please fill out the following questionnaire. All responses are confidential.

This form is for current clients of Afterbirth Anywhere. If you would like to become a client and have not yet completed a contract, please email AfterbirthAnywhere@gmail.com to request one.

Full Name *

Phone number *

Estimated Due Date or Date of Birth *

YYYY

Any health concerns with this pregnancy? *

Some conditions are incompatible with encapsulation, such as severe pre-eclampsia and severe gestational diabetes. Please list any current medical condition below or if any conditions such as these are identified, please notify us immediately.

Are you taking any medications this pregnancy, other than prenatal vitamins?

Do you have any specific health issues that could place anyone at risk who comes into contact with your placenta?

-Specifically bloodborne pathogens such as HIV or Hepatitis, etc.

Are you a vegetarian?

-We have vegetarian capsules available upon request only.

yes

Clear selection

Please list any additional food allergies or limitations.

-Relevant to smoothie, tincture, or truffle preparation.

Why have you chosen to encapsulate your placenta?

Additional comments: Is there anything else we should know, or that you would like to share with us?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms