Sacred Seasons Birth Order Form

Service Contract & Order Form

Thank you for choosing Sacred Seasons Birth! Please complete the order form and service contract below. Please remit your $150 non-refundable deposit immediately upon receipt of the payment request. As soon as I receive your completed forms, I will issue the payment request via your preferred payment platform indicated below. I must have the completed forms and the $150 deposit to secure your place on the service schedule. If you have questions or need clarification, please contact me at (940) 230-6690. I look forward to serving your growing family!
Client Name*

First NameLast Name
As of today, how many weeks pregnant are you?*
Baby's Due Date *

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner/Support Person*

First NameLast Name
Partner/Support Person's phone number *
Please enter a valid phone number.
Do you have a doula or secondary support person?*
If you you plan to have a doula, family member or friend (other than the person listed above) that may be responsible for collecting the placenta, please provide their information below.
Doula/secondary support person’s name*
Doula/secondary support person’s phone number *
Please enter a valid phone number.
How did you hear about Sacred Seasons Birth?*
If someone referred you, please provide their name so I can personally thank them !
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 and deposit. This provides one thread for everyone to be on the same page and easily communicate with one another regarding your placenta.
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 to receive a 5% discount code! Please be sure to input that code in the discount code box at the bottom of the form.
Are you a veteran, active-duty service member, or first responder? *
Please upload your DD214, current orders, or current proof of employment to receive a 5% discount code! Please be sure to input that code in the discount code box at the bottom of the form.
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
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 complications in your pregnancy?
If “yes”, please briefly explain below
If “yes”, please specify.
This does not necessarily exclude you from encapsulation. Only in situations of an infection of the placenta will I be unable to encapsulate for you.
Do you have any allergies? *
Please include any food, environmental and/or seasonal allergies.
If “yes”, please specify *
Please list any specific food allergies
Are you expecting multiples (twins or triplets)? *
I do not charge double for multiples. There is a small materials fee associated with multiples.
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.
Have you tested positive for any bloodborne or other highly contagious illness such as HIV, Hepatitis A,B,C, etc.?*
Answering "yes" to this question does not preclude you from encapsulation. I is strictly as a professional courtesy to our encapsulation specialist.
If "yes", please specify.
My preferred payment platform is*
You may change your preferred payment platform before remittance of your remaining balance if needed.
Please provide the phone number, email address, or cashapp tag for the payment request(s) below
Please indicate if you’d like to pay the deposit or the full balance at this time.
Payment plans are available upon request. Payments may be split up into 2-4 payments throughout your pregnancy. Any remaining balance is due at the time of delivery. NOTE: if you select the "expedited delivery" option for your placenta collection kit, the deposit amount due is $200 not $150.
Permission to Post a Birth Announcement

Having a baby is so exciting! If I am given permission, I will make a "Welcome Baby Girl" or "Welcome Baby Boy" post on my social media accounts for SSB. I do not include any personally identifying information of yours or your child's. The post only include just the sex of the baby and the city in which they were born. If you give limited permission, the post simply says "Welcome Baby" with no gender or location specified. If you'd like to add stipulations to your permission, please specify below!
(You see examples of these types of posts, on the Sacred Seasons Birth Facebook or Instagram pages!)
Birth Announcement Permission *
If you’ve given limited permission, please specify below
Baby's Gender
Limited Permission Specifications *
Please be as specific as possible

Please complete the order form below. Selections for Placenta Encapsulation and Cord Keepsake are automatically added to your order, but you will need to specify your preferences via the drop-down boxes in those sections. The quantity-selection boxes in the add-ons section begin with the number one but are not automatically added to your order. To add one (or more) of these items to your order, click on the box located to the left of the item title. Once added, a checkmark will appear in the box and the item subtotal will change from $0.00 to the price of the item(s) added. *

Placenta Capsules

Preparation MethodPlease select your preferred preparation method. TCM (Traditional Chinese Method)- the placenta is gently steamed with organic grated ginger, jalapenos (grown in our very own garden), and lime added to the water as the placenta steams in a double boiler. Simple Prep- no steam is added to the placenta before the dehydration process. 1/2 & 1/2- half TCM method and half Simple Prep Single Birth- one baby born Multiple Birth- more than one baby born

$385.00 Are you expecting a single baby or multiple?Preferred Preparation Method
Item subtotal:$0.00

Expedited Shipping for Placenta Kit Product Image

Expedited Shipping for Placenta KitIf you are already past 36 weeks of pregnancy and/or would like to have your placenta collection kit expedited to you (within 24-48 hours), please select expedited shipping of placenta kit. By selecting this option, you understand the deposit amount due upon submission of this order form is $200, not $150.

$50.00 Expedited Shipping of Placenta Collection Kit

Keepsakes

Umbilical Cord Keepsake Preference Product Image

Umbilical Cord Keepsake Preference A truly unique keepsake made by removing the remaining umbilical cord from the placenta, formed into a desired shape and dehydrated completely. If you have a special request be sure to enter that in the note section on the bottom of this order form

$ Free Would you like a cord keepsake? Preferred ShapePreferred Finish
Item subtotal:$0.00

Placenta Prints Placenta prints are made by gently pressing high-quality watercolor paper onto the baby's side of the placenta, absorbing the residual fluids, and revealing a "stamp" of the placenta. The back of each print is dated, signed by Kelli Stone, and has a short personalized message. Each order comes with 2 prints. The first set is $35. Each additional set is $10 each

$ Free Quantity
Item subtotal:$0.00

Add-On Items

Placenta Tincture (4oz)This is a powerful addition to your postpartum regimen. Placenta tinctures take a minimum of 6 weeks to cure, so it is not intended to replace your capsules. Made with 90-proof potato vodka and a small portion of your raw placenta, resulting in 4 ounces of a highly concentrated elixir that lasts for months to years! As your tincture begins to run out, simply add more vodka to the bottle, with the remaining placenta piece still in the bottle, and allow it to cure for a minimum of 6 weeks. The first tincture is $45. Any additional tincture is $20 each.

$45.00 Quantity
Item subtotal:$0.00

Placenta Tincture (2oz)This is a powerful addition to your postpartum regimen. Placenta tinctures take a minimum of 6 weeks to cure, so it is not intended to replace your capsules. Made with 90-proof potato vodka and a small portion of your raw placenta, resulting in 4 ounces of a highly concentrated elixir that lasts for months to years! As your tincture begins to run out, simply add more vodka to the bottle, with the remaining placenta piece still in the bottle, and allow it to cure for a minimum of 6 weeks.

$25.00 Quantity
Item subtotal:$0.00

Placenta Salve (4 oz)DO NOT USE ON BABY. An incredibly powerful healing balm full of the medicinal properties of the herbs, oils, and stem cells from your placenta. Each salve is made-to-order by infusing a small amount of your placenta powder with purely organic oils and butter (such as mango and coconut), all organic, ethically sourced calendula flower, plantain leaf, comfrey root powder, beeswax, and vitamin E. We DO NOT add essential oils or preservatives to the mixture, which makes it 100% safe for use on episiotomy or C-section scars (once your doctor clears you to do so). This salve is for use on mom ONLY. Due to the hormone content, use on baby may cause swollen nipples or genitals. The first salve is $65. Additional salves are $25 each.

$65.00 Quantity
Item subtotal:$0.00

Placenta Salve (2oz)An incredibly powerful healing balm full of the medicinal properties of the herbs, oils, and stem cells from your placenta. Each salve is made-to-order by infusing a small amount of your placenta powder with purely organic oils and butter (such as mango and coconut), all organic, ethically sourced calendula flower, plantain leaf, comfrey root powder, beeswax, and vitamin E. We DO NOT add essential oils or preservatives to the mixture, which makes it 100% safe for use on episiotomy or C-section scars (once your doctor clears you to do so). This salve is for use on mom ONLY. Due to the hormone content, use on baby may cause swollen nipples or genitals.

$45.00 Quantity
Item subtotal:$0.00

Nourishing Salve (4oz)SAFE FOR BABY. An incredibly powerful healing balm full of the medicinal properties of the herbs, butters and oils. Each salve is made-to-order by infusing all organic, ethically-sourced ,calendula flower, plantain leaf, comfrey root powder, beeswax, vitamin E and more. We DO NOT add essential oils or preservatives to the mixture, which makes it 100% safe for baby and use on cracked/sore nipples, baby acne, diaper rash, circumcision wounds, and many other minor cuts/skin irritations.,The first salve is $65. Additional salves are $25 each.

$65.00 Quantity
Item subtotal:$0.00

Nourishing Salve (2oz)SAFE FOR BABY. An incredibly powerful healing balm full of the medicinal properties of the herbs, butters and oils. Each salve is made-to-order by infusing all organic, ethically-sourced ,calendula flower, plantain leaf, comfrey root powder, beeswax, vitamin E and more. We DO NOT add essential oils or preservatives to the mixture, which makes it 100% safe for baby and use on cracked/sore nipples, baby acne, diaper rash, circumcision wounds, and many other minor cuts/skin irritations.,The first salve is $45. Additional salves are $20 each.

$45.00 Quantity
Item subtotal:$0.00

Enter coupon

Total

$0.00

Please put any custom requests or other important information in the box below.
If you need clarification prior to submission, please call or text Kelli Stone 940-230-6690

Below is important information. PLEASE read before completing and submitting your form. If you have questions, concerns, or need clarification, contact Kelli Stone at 940-230-6690 before submitting your order form.

Preparation

Once I've received your order form and non-refundable $150 or $200 deposit I will:
- process your order form
- add you to the service schedule
- send you a copy of your order form and an invoice
- send out a welcome text message that will include myself, you, and your support person(s). This chat thread should be utilized to keep me informed on your delivery and shipping status of your placenta.
- I strongly encourage you include at least one support person in this chat thread, to ensure all pertinent parties can communicate effectively and efficiently regarding your placenta.
Be sure to notify me in the group thread, regardless of the time of day, if/when:
- You have been admitted to your birthing facility
- Once you deliver and your placenta is safely SECURED*.
- Once you've shipped your placenta back to me
- If the facillity is giving you pushback regarding releasing your placenta. If at any point you receive pushback, CALL ME immediately 24/7 and I will help you navigate the opposition.
- You have any questions or concerns at any time through your journey. I am available to you 24/7/365.
Due to most facilities implementing arbitrary policies stating the placenta must be removed from the campus within 60 minutes of delivery (time may vary from facility to facility), I strongly encourage your support person to take the *secured placenta to your vehicle until the placenta can be taken home and placed in the freezer.

*Secured means the placenta has been triple bagged in the collection bags provided in your kit, buried with 2 inches of ice under the placenta and 2 inches of ice on top of it, inside the provided cooler, and is safely in your possession or that of your designated support person.

The placenta must be put in ice within 4 hours of delivery and can remain on ice (or in a refrigerator) for UP TO 72 hours before it must be frozen.

Order Form and Contract

I require the following before you are added to the service schedule and your placenta collection kit is mailed out
- A completed order form and contract
- Remittance of either the $150 non-refundable deposit, $200 non-refundable deposit, or the full amount of your order.
"Same-Day" Clients

It is always best to secure services as early in your pregnancy as possible, however, I understand life happens, so I do accept clients who are due any day or who have recently delivered, so long as the following conditions are met.
- The placenta was properly secured, on ice, within 4 hours of delivery.
- The placenta was kept on ice or refrigerated for no more than 72 hours and/or was placed into the freezer no more than 72 hours after delivery
- You gave birth no more than one week ago.
Deposit and Itemized Invoice

A $150 non-refundable deposit is due when you submit your completed order form and contract, unless you need your placenta collection kit expedited to you. In that case an additional $50.00 is due with your $150 deposit to cover the cost of the rush shipping, bringing the balance to $200 due at the time of form submission. The $150 deposit goes toward your overall balance, secures your place on the service schedule, secures your placenta collection kit and its (normal) shipping, as well as the return shipping costs of your placenta to Sacred Seasons Birth. As soon as I receive your order form, contract, and deposit, I will send a copy of your order form and invoice to you.

Payment Options

I only require the $150 non-refundable deposit be paid at the time you submit your order form and contract (unless you need the placenta collection kit rush shipped to you it is $200). However, you are welcome to pay the entire balance in full if you prefer.

Any remaining unpaid balance must be paid, in full, once you deliver and secure the placenta. Failure to remit the final balance in the specified timeframe will result in delays of: the processing of your placenta, return of your placenta product(s) to you and could result in an additional storage fee. Unless prior arrangements are made, the follow applies:
- If I have not received the remaining balance due within 72 hours of delivery and I've had no communication from you I will consider your order form/contract null and void, and will remove you from the service schedule.
- If you decide after the allotted 72-hour time frame that you'd still like to encapsulate your placenta, you must contact me to complete a new order form, sign a new contract, and remit the balance due immediately.
- If I receive your placenta in the mail but haven't received the remaining balance due, you have 72 hours from the time I issue proof of receipt of your placenta to remit the payment in full.
- If after 72 hours from receiving your placenta no communication or payment has been received, a $75 placenta storage fee will be added to the total balance due.
- If after 14 days, no communication has been received from you and/or the total balance due, INCLUDING THE $75 STORAGE FEE, has not been remitted, your placenta will be disposed of and your contract is null and void.
Payment plans are available upon request, for the duration of your pregnancy, and can be broken up into 2, 3, or 4 installments. Any remaining balance is due at the time of delivery.

The following are the only forms of payment accepted for remittance of the deposit or total balance paid in advance. The remaining balance may be paid in cash if that arrangement is made before delivery.

Zelle: Kelli Stone 940-230-6690

Apple Pay: 940-230-6690

CashApp: $placentacapsules

I am a small company and do not have a credit card processing machine. However, under certain circumstances I can accept credit cards via Stripe. If you have to use a credit card to pay, please contact me immediately to make sure you're eligible to do so. An additional $15.00 processing fee is added to your total due in order to cover the astronomical processing fees that are placed on small businesses.

I am SOMETIMES able to accept HSA cards. I can always try to run the card through Stripe. Depending on who your HSA admin is, it might go through immediately without issue, they may come back at a later date and ask you to justify the expense, or it may decline immeditately. There is really no way of knowing until we try. If your HSA card runs successfully by the company asks you to justify the expense at a later date, let me know and I will help you craft a response to them.

Refunds

Refunds are determined at the sole discretion of me (Kelli Stone), on a case-by-case basis.

Delivery of Products

Your final product(s) are shipped, via a USPS-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 me receiving the placenta.
- Delivery may take 1-3 business days, depending upon USPS closures/holidays/inclement weather.
- Once the package has been submitted to USPS, a tracking number will be provided to you in the group chat.
- Once the tracking number has been provided to you, I (Kelli Stone) AM NO LONGER responsible for lost or damaged packages by USPS.
- Your package will be insured to the full amount you paid.
- In the event of a lost package or damaged product(s), you are responsible for initiating and maintaining a claim with USPS to pursue reimbursement, as well as following all required prompts and protocols laid out by USPS, within any specified time frame given.
Sacred Seasons Birth Order Form and Service Contract

Please carefully review and complete the service contract below. If you need clarification, contact me IMMEDIATELY at 940-230-6690 before submitting this form.
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.
- I understand that results may vary for every woman and each of her pregnancies. As such, 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 all 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 understand consuming my placenta products during times of illness, such as the common cold, flu, mastitis, etc. may cause a worsening of my symptoms. I will stop using my placenta capsules until the symptoms of the illness subside. initial here*
- I agree to disclose to SSB/Kelli Stone and/or their representatives if they will be exposed to any blood-borne pathogens or highly communicable diseases, such as but not limited to, HIV, Hepatitis, MRSA, etc. in the space provided above. I understand testing positive for any of the aforementioned (or the presence of meconium at birth) does not preclude me from encapsulating my placenta inital here*
- I agree to notify the birthing facility, via my nurse, at the time of admittance, that I am keeping my placenta, request for my nurse to chart that information and request the nurse bring me any required placenta release paperwork to sign, as soon as possible. I agree that I and/or my support person(s) will assert my right to keep my placenta should I receive pushback initial here*
- I agree to call Kelli Stone immediately if the facility, care provider, or nurse refuses to release my placenta or if I feel I may be at risk of having my placenta taken from me. initial here*
- I assert my placenta is properly stored, triple bagged, buried in a minimum of 2 inches of ice, (both under the placenta and on top), in the disposable cooler, within 4 hours postpartum. I understand the placenta may be kept on ice (replenished every 8-12 hours or as needed) or refrigerated, up to 72 hours postpartum before it MUST go into the freezer. I understand my placenta must be frozen for 48-72 hours prior to mailing my placenta to SSB/Kelli Stoneinitial here*
- I agree to maintain possession of my placenta from the time of delivery until my support person can place the secured placenta in the car or take it home to be property frozen. I understand if my placenta is taken to the hospital lab, or stored anywhere other than in the possession of myself, or my designated representative, the proper chain of custody has been broken and my placenta at risk of cross-contamination (chemicals, blood, and other bodily fluids from other people, etc.), being lost, stolen, disposed of by the facility, or accidentally switched with another placenta not belonging to me. initial here*
- I agree to pay the $150 or $200 (if applicable) non-refundable deposit at the time of contract submission, via one of the approved payment methods stated within this form. I understand the remaining balance is to be remitted at the time of delivery. initial here*
- I agree to notify SSB, immediately, if a payment plan (not exceeding more than 4 installments) needs to be arranged. I understand payment plans are only available through the duration of my pregnancy and any remaining balance must be remitted, in full, at the time of delivery. initial here*
- Same-day clients: I understand and agree to remit the full balance, not just the deposit, for services at the time I submit my order form for SSB to mail my placenta collection kit and be added to the service schedule. initial here*
- I agree to notify Kelli Stone via a text message, in the designated group chat, of all pertinent updates regarding my placenta delivery progress and shipping of my placenta. I agree to mail my placenta to SSB/Kelli Stone Monday- Wednesday to ensure my placenta is delivered appropriately. I understand mailing my placenta any later than on a Wednesday, may put my placenta at risk of not being delivered within the appropriate time frame, and may cause my placenta to thaw to the point it may no longer be viable for encapsulation. I take responsibility for mailing my placenta properly and within the correct time frame.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:

Service Contract & Order Form

Permission to Post a Birth Announcement

Below is important information. PLEASE read before completing and submitting your form. If you have questions, concerns, or need clarification, contact Kelli Stone at 940-230-6690 before submitting your order form.

Preparation

Order Form and Contract

Sacred Seasons Birth Order Form and Service Contract