Hudson Valley Placenta Services Registration
Thank you for choosing Hudson Valley Placenta Services to provide your placenta services. HVPS was the first to offer professional placenta services in the Hudson Valley region and continues to offer the same high quality services that have satisfied many new families since 2009. Please complete this form if you have spoken with Suzie Dougherty D'Angelo and have been instructed to do so. Please complete the following Client History information, read through the General Information and Policies, and note your preparation preferences along with any information related to your services that we should be aware of. Please initial where indicated and type your name & the date at the end, as an electronic signature. HVPS respects your right to privacy and assures you that all answers are held in strictest confidence. Please save a copy of the confirmation & handling instructions page for your records following completion of this form. The handling instructions are also included in the Transport Kit which will be mailed upon receipt of your deposit. We look forward to serving you and your family!
First & Last Name *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Full Home Address (Street, City, State & Zip Code) *
Your answer
Primary E-Mail Address *
Your answer
Primary Phone Number (home or cell) *
Your answer
Alternative Phone Number (home or cell)
Your answer
Partner/Relationship of contact person, if applicable. Example: Suzie/Doula, Vicki/Mother, etc.
Your answer
Please specify planned birth place *
Have you had any of the following during this pregnancy (please check all that apply even if you have been treated, make a note in the "Other" Category if you have a history of the following or any that are not listed) *
Required
Please select your preparation preferences (please check all that apply) *
There is no extra charge for any service listed
Required
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.