Memory Keepsake Consent & Order Form

Memory Keepsake Consent Form

Please provide your details and consent to create a personalized keepsake for your baby. This service is made available to you for free by your hospital.
Your Hospital/Facility's Name
e.g. "Novant Health PMC Charlotte"
Name of Nurse/Staff Helping With This Form

First NameLast Name
Parent's Full Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Baby's Name
Baby's Birthdate or Other Special Date

MonthDayYear
Date
Upload Baby's Footprint Images

Cancelof
Privacy & Consent
By submitting this form, you authorize Gemma's Hope to use the information provided to create a customized keepsake in memory of your baby. Your information will be securely shared with our trusted partner, LazerEdge, solely for the purpose of fulfilling your order. All information will be permanently deleted immediately after your order is fulfilled.
Should be Empty:

Memory Keepsake Consent Form