Sacred Seasons Birth Order Form

Sacred Seasons Birth New Client Order Form

Thank you for choosing us! We look forward to working with you. Please review the information carefully and do not hesitate to reach out if you have questions or concerns
Client Contact Information
Your Full Name

First NameLast Name
Baby’s Due Date

MonthDayYear
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Your Address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Partner/Support Person

First NameLast Name
Your Partner/Support Person's phone number
Please enter a valid phone number.
Do you have a doula or secondary support person?
If “yes” please provide their name and contact below.
Doula/secondary support person’s name
Doula/secondary support person’s phone number
Please enter a valid phone number.
Would you prefer future text communications include your spouse/doula/secondary support person(s)?
You will receive a group text that will include you, myself (Kelli), and your support person(s) once I receive your form.
Are you giving birth in a hospital?
If you are giving birth somewhere other than your home, please provide the name and address of that location below.
Birthing Location
The name of the birth center or hospital. If birthing at home , simply type “home”.
Address of Birthing Location

Street Address

Street Address Line 2

CityState

Zip Code
Are you giving birth outside of my service radius?
If “Yes. I’d like to pay mileage…”, be sure to mark the appropriate distance on the order form in the “Placenta pick-up outside of service area” section. If your support person is meeting me with the placenta within my service area, there is no additional charge, so you will mark “N/A” in that section.
Your preferred payment platform
You may change your preferred payment platform at a later date.
What is the username, telephone number or email address associated with your account?
I use this information to send payment requests. If we have arranged a cash payment, put "N/A" in the blank above.
How did you hear about Sacred Seasons Birth?
If someone referred you, please provide their name so I can personally thank them.

Important Questions & Health Information

It is very important to establish any health risks or other hazards. Answering "yes" to any of the questions below does not automatically disqualify you from encapsulation. This information allows me to have a more thorough understanding of your specific needs and make proper preparation decisions.
Are you currently experiencing any significant emotion complications such as anxiety, depression, Bipolar disorder, DID, etc.?
If “yes” please briefly explain below
If “yes”, please specify.
This does not exclude you from encapsulation
Are you experiencing any physiological complications in your pregnancy?
If “yes”, please briefly explain below
If “yes”, please specify.
The only complication that will exclude you from encapsulation is if there is an active infection in which you are running a fever and given antibiotics during labor
Do you have any allergies?
Please include any food, environmental and/or seasonal allergies.
If “yes”, please specify
Please list any specific food, environmental and/or seasonal allergies
Have you tested positive for any bloodborne or other highly contagious illness such as HIV, Hepatitis A,B,C, MRSA, etc.?
Answering "yes" to this question does not exclude you from encapsulation. It is strictly as a professional courtesy to our encapsulation specialist that this information be provided
If "yes", please specify.
Are you expecting multiples (twins or triplets)?
I do not charge double for multiples. There is a small materials fee associated with multiples.
Including this one, how many pregnancies have you had?
Are you Group B Strep Positive?
This does not exclude you from encapsulation. I have specific protocols I follow to ensure the proper cleanse has been done for the placenta.

Special Qualifications

We offer discounts on encapsulation for first responders, services members, veterans, and Medicaid recipients. If you or your partner fall into one of these categories, please provide the information below to receive the discount
Are you a veteran, active-duty service member, reservist, or first responder?
If you do not see the option that best describes you, pick the closest one listed, then upload your status verification in the upload box below.
Are you currently a Medicaid recipient?
Please provide proof of current Medicaid coverage by uploading your most recent approval letter from HHSC in the upload section below.
Identity Verification

Ex: DD214, current active duty orders, a current w-2 from your place of employment or current Medicaid approval letter
Cancelof
You are eligiable for a 5% discount on encapsulation services. Enter this code in the coupon box at the bottom of the order form to apply the discount!

MEDICAID
Thank you so much for your service and sacrifice. Please enjoy 5% off of encapsulation services by entering the code below in the coupon code box at the bottom of the order form

SERVE
Be sure to enter your discount code!!

At the end of the order form there will be a place to enter a coupon code. Be sure to enter your code for it to be applied to your order

Permission to Post a Birth Announcement

If we are given permission, we will make a "welcome baby" post on our social media accounts. No identifying information is posted, just the sex of the baby and the city in which they were born.
Birth Announcement Permission
If you’ve given limited permission, please specify below
Birth Announcement Permission
If you’ve given limited permission, please specify below
Limited Permission Specifications
Please be as specific as possible
Baby's Gender

Important Information

The sections below explain in detail the order of operations and necessary procedures. Please review them carefully.
Preparation & Order of Operations
The following is a list of items you should take to the hospital, and arrangements to make ahead of time so that everything goes as smoothly as possible on the big day.
- 2 one-gallon-sized ziplock bags
- a small styrofoam or otherwise disposable cooler (for sanitation reasons, we cannot return a hard-sided cooler once it has been used to secure and transport your placenta)
- a copy of your birth plan
- designate a support person responsible for ensuring the placenta is secured and protected
You will receive a welcome text message in a thread that includes you, your support person, Kelli Stone, and whomever else you indicate on the order form. This chat thread should be utilized to keep SSB/Kelli informed on your labor and delivery status. We strongly encourage your support person to be included in this chat thread to ensure all pertinent parties can communicate effectively and efficiently on the day you give birth.

Be sure to notify Kelli via a text in the designated group chat, 24/7:
- if your water breaks
- you are in active labor
- have been admitted to the birthing facility
- once you begin to push or just before being taken back for a C-section
Once you've delivered and the placenta is secured
- you or your support person needs to approve the final payment request
- CALL (not text in the group thread) Kelli to give notice the placenta is ready for transport
- maintain possession of the placenta until we arrive.
*Secured means the placenta has been placed in a leakproof container, with a lid, or has been double-bagged in plastic ziplock bags, buried with 2 inches of ice under the placenta and 2 inches of ice on top of it, inside a DISPOSABLE cooler and safely in the possession of the client, her support person, or otherwise designated representative.

If you are birthing at home, there is no pressure to contact us immediately following delivery. You have up to 72 hours postpartum to call and notify us that you've delivered and are ready for transport.
Order Form and Contract
We require the following for you to be added to the service schedule and for us to guarantee services at the time of your delivery:
- A completed order form and contract
- Remittance of the $75 non-refundable deposit, or the full amount of your order, whichever you prefer.
Deposit & Itemized Invoice
The deposit is only applicable to clients who are securing services ahead of their delivery date. A $75 non-refundable deposit is due when you submit your completed order form and contract.
The $75 goes toward your overall balance and guarantees service on the day you deliver. As soon as we receive your order form, contract, and deposit, we will generate an itemized invoice reflecting
- items ordered
- the price of each item
- total balance due
The invoice will not reflect the paid deposit, but any remaining balance will be stated in the welcome message you will receive once we have processed your order.

If you have private insurance, submit the invoice to them, after the baby is born, for possible reimbursement for the cost of encapsulation. We are not directly associated with any insurance companies, so we cannot guarantee you will be reimbursed. If your provider asks for supporting documentation, let us know and we will provide whatever they are asking for.

Same Day Clients
We do accept clients who are currently in labor or have recently delivered, so long as the following conditions are met.
- The placenta was properly secured within 4 hours postpartum.
- The placenta can be kept on ice (replenished every 8-12 hours, as needed) or refrigerated for up to 72 hours.
- After 72 hours, the placenta must be frozen.We highly recommend removing the placenta from the leakproof container and double-bagging it before freezing it.
It is a requirement for same-day clients to pay their full balance at the time the order form is submitted. We cannot dispatch out to your location, nor take posession of your placenta, until the balance has been remitted in full.
Payment Options

If you do not see your preferred payment platform listed, please contact us before submitting your order.
We only require the $75 non-refundable deposit to be paid when you submit your order form and contract. However, you are welcome to pay the entire balance if you prefer.

Any remaining unpaid balance must be paid, in full, once you deliver. Once we have confirmation that you have been admitted to the hospital (if applicable), we will issue the remaining balance request via your preferred payment platform. We cannot dispatch to your location until your balance is fully paid. Failure to remit the final balance delays the processing and return of your placenta product(s).

Payment plans are available, upon request, for the duration of your pregnancy. Payments can be broken up into 2, 3, or 4 installments. Any remaining balance is due at the time of delivery.

The following are the preferred payment platforms. The remaining balance may be paid in cash if arrangements are made prior to delivery.

Zelle

User Name: Kelli Stone

Phone Number: 940-230-6690

Apple Pay

Phone Number: 940-230-6690

CashApp

CashTag: $placentacapsules

Venmo

username: @Sacred_Seasons_Birth

We are a small company and do not have a credit card processing machine. To utilize a credit card we have to use Square. If you require using a credit card via Square, you must pay the entire balance at the time you submit your order form and contract. Square withholds funds collected from credit cards for up to 21 days before releasing them to us and charge a substantial processing fee. An additional $15 will be added to your total balance to cover those fees.

We can SOMETIMES accept HSA cards. Some HSA companies approve charges with no hassle. Others immediately decline the charge with no means for appeal. Yet others will approve or deny the charge then ask for further supporting documentation before making their final decision. If your company asks for more documentation, we will happily provide it for you.

Refunds
Refunds apply ONLY to clients who paid in full, SSB has not taken possession of the placenta yet and are:
- Determined at the sole discretion of Kelli Stone, on a case-by-case basis.
- Issued in the total amount paid, minus the one-time, non-refundable $75 deposit.
- Not issued after we take possession of the placenta
In the case of a birthing facility error or refusal to release the placenta, for any reason, you are obligated to pursue the birth facility for a full/partial refund for the loss of funds for encapsulation services. We cannot guarantee reimbursement will be given by the birth facility.

You are required to:
- Notify the charge nurse on duty as soon as possible of the situation.
- Contact the birth facility's patient advocate and/or ombudsman to initiate the reimbursement from the birth facility.
- Document everything as it happens, preferably via recordings and written notes.
- Gather and submit all requested/required documentation as expressed by the birthing facility, to the appropriate parties, within the designated timeline, to resolve the issue properly.
Shipping Final Products

All packages shipped via USPS or UPS insured packages.
Your final product(s) are shipped, via a USPS or UPS (the brown company) insured package, to the address you designate on the order form, unless otherwise specified.
- Your products will be shipped to you within 72 hours of us receiving the placenta.
  Delivery may take 1-3 business days, depending upon carrier closures/holidays/inclement weather.
- Once the package has been submitted to the carrier, a tracking number will be provided to you in the group chat.
- After the tracking number has been provided to you, SSB/Kelli IS NO LONGER responsible for lost or damaged packages by the carrier.
Your package will be insured to the full amount you paid to for services, so in the event of a lost package or damaged product(s), you are responsible for:
- Initiating and maintaining a claim with the carrier for reimbursement
- Following all required prompts and protocols laid out by the carrier, within the specified time frame
- Continuing to document everything until the case is closed

Sacred Seasons Birth Order Form and Service Contract

Please carefully review and complete the service contract below. The $75 non-refundable deposit is due at the time order form is submitted
I,   First Name*   Last Name*, (henceforth "I"), have requested Sacred Seasons Birth/Kelli Stone (henceforth "SSB") to prepare my placenta, in capsule form, for my personal use. As a condition of service, I make the following assertions, freely and of my own volition. Initial Here*

I understand that results may vary for every woman and each of her pregnancies. I acknowledge no guarantee of results is neither offered, nor implied, by SSB or its representatives. Initial Here*

I release SSB, Kelli Stone, and all SSB representatives from any liability associated with any unwanted side effects I may experience after consuming my placenta products.   Initial Here*

I understand that services rendered by SSB are not intended to diagnose or treat illness or injury of any kind. SSB provides placenta preparation services, for personal use, only. Initial Here*

I understand that the FDA has not evaluated the statements made by SSB, Kelli Stone, or their representatives.   Initial Here*

I understand the guidelines provided for using my placenta products are for reference only. I assert I will listen to my body and adjust product usage according to my needs.
Initial Here*

I agree to disclose to SSB if their representatives will be exposed to blood-borne pathogens, or communicable diseases, in the space provided above.   Initial Here*
I understand testing positive for blood borne pathogens or the presence of meconium at birth does not preclude me from encapsulation.  Initial Here*

I agree to notify the birthing facility, at the time of admittance, that I am keeping my placenta, request for my nurse to add that information to my chart and bring me any required placenta release paperwork to sign. Initial Here*

I assert my placenta will be properly stored in a leak-proof container, with a lid, or double-bagged, in plastic Ziplock bags, buried ice, in a disposable cooler, no more than 4 hours postpartum.    First Name*

I agree to maintain possession of my placenta, from delivery, through my stay at the hospital or until SSB takes possession of it.   Initial Here*

I agree to pay the $75 nonrefundable deposit at the time of contract submission, via one of the approved payment methods stated within this form. Initial Here*

Same-day clients: I understand and agree to remit the full balance, not just the $75 non-refundable deposit, for services at the time I submit my order form. I understand SSB cannot dispatch to my location without the balance remitted in full.   Initial Here*

I agree to notify Kelli Stone via a text message, in the designated group chat, of all pertinent updates regarding my labor and delivery progress. I understand I have direct access to Kelli Stone 24/7 and can contact her as needed.   Initial Here*

I understand I, or my support person, must call, not just text, Kelli Stone once the placenta has been secured and is ready for transport.   Initial Here*

I have read, understand, and agree to the terms and conditions outlined herein and assert the answers are correct to the best of my knowledge.   Initial Here*

     Signature*   Date*
Should be Empty:

Sacred Seasons Birth New Client Order Form

Client Contact Information

Important Questions & Health Information

Special Qualifications

Be sure to enter your discount code!!

Permission to Post a Birth Announcement

Important Information

Preparation & Order of Operations

The following is a list of items you should take to the hospital, and arrangements to make ahead of time so that everything goes as smoothly as possible on the big day.

Order Form and Contract

Deposit & Itemized Invoice

Same Day Clients

Payment Options

Refunds

Shipping Final Products

Product Order Form

Sacred Seasons Birth Order Form and Service Contract