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Intake Form

To book your placenta encapsulation, please fill out the client intake form and pay the $50 deposit.



1). Complete the Client Intake Form

Client Information/Instructions                                

I recommend printing a copy of the Information/Instructions, and either placing in a visible location in your home (home   birth) and/or packing in your hospital bag so that you're able to refer to it when you deliver.

Waiver of Liability/Services Agreement

Please print, initial, and sign the Waiver/Services Agreement. I will collect it from you when I pick up your placenta, or you   may scan a signed copy and email it to me.

Hospital Printout (Optional)

Print and pack this in your hospital bag. Hang in your room as a reminder to the hospital staff that you wish to keep your placenta.

2). Pay the booking deposit or pay in full

Placenta Encapsulation Services - TCM Inspired Method

Booking Deposit: $50

Please note the booking deposit is non-refundable. 
The remainder of the balance for services rendered is due at the time I pick up your placenta to begin preparation, and can be paid via PayPal, Venmo, debit/credit card, or by cash.

If you wish to take care of this in advance, you may pay in full now.

3). Download & print the Client Information/Instructions & Waiver of Liability/Services Agreement

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