Placenta Order Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone - This is a number the courier can call when they arrive for pickup. Someone who has just given birth may be unavailable for answering the phone at this time, so a secondary number is handy.

Please enter a valid phone number.Format: (000) 000-0000.

What is the best address for delivery of your placenta kit/pills?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Baby's Due Date

Date

Planned Birth Location

Basic - Placenta Pills ($249)Classic - Placenta Pills, 1 placenta product ($269)Deluxe - Placenta Pills, Transport Kit, 2 placenta products, streamed breastfeeding class, postpartum journal ($289)

Clear VegetarianBerry

TinctureSalveHerbal BathPrint

Raw (sliced raw, dehydrated at 160 degrees)Traditional Method - TM (steamed, sliced and dehydrated at 160 degrees)

Yes, I want the cord dried naturally (free)No, I don't want my cord.Yes, I want a "gold plated" cord

Yes, I want the cord dried naturally (free)No, I don't want my cord.

How'd you hear about us?

Choose your encapsulation package. All packages include placenta pickup via medical courier, processing, pills and delivery of your products to you.

Basic Placenta Package

Placenta Pills ($249)

$249.00 Quantity

Classic Placenta Package

Placenta Pills, 1 placenta product

$269.00 Quantity

Deluxe - Placenta Pill

Transport Kit, 2 placenta products, streamed breastfeeding class, postpartum journal

$289.00 Quantity

Gold Cord

$7.00 Quantity

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

If your or your baby develops an infection at the time of delivery or within the following 24 hours after delivery - it is important to let us know so we can determine the safest options. Initial that you will notify us within 24 hours if an infection is diagnosed. (Please note, a positive GBS status is NOT an infection.)*

I understand that I am responsible for storing the placenta on ice or in other refrigeration, calling for pickup in a timely manner and having someone available to hand the placenta to the courier when he arrives. We cannot refund if the placenta was not on ice/refrigeration for more than 2 hours or if you fail to contact us at 833-PLACNTA concerning pickup. You are responsible for any extra courier fees due to wait time at the pick up location.*

When you submit your order, an encapsulator will be put on call so we are ready whenever your baby arrives. You will receive an email with our on call number for pickup and answers to frequently asked questions. Refunds (minus any costs incurred) are only provided when a placenta cannot be safely encapsulated due to infection. Please note, neither a positive GBS status nor meconium is a contraindication for encapsulation, thus is not eligible for a refund. However, we work with all hospitals, pathology labs, birth centers and providers and can assist you as needed.Draw your signature into the box below to acknowledge the terms of the above contract.*

Great Expectations Birth is not a licensed medical professional and does not diagnose, treat, or prescribe for any health condition. No specific benefits are promised and benefits have not been evaluated by the FDA. It is your responsibility to determine if using placenta preparations may be of benefit to you. Placental supplementation is intended solely for ingestion by the individual who has birthed the placenta(s). It is your responsibility to discuss release of your placenta from your place of birth. Your placenta should not be treated with alcohol, formalin or any other preservative. If it is, it is no longer eligible for encapsulation. To insure pickup, please call the 833-PLACNTA number rather than our office line.*

I agree