Precious Placentas booking form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email address
*
example@example.com
Birth Partners Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Birth Number
Estimated Due Date
*
-
Day
-
Month
Year
Date
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Which hospital will you be having your baby?
*
Please specify if it’s a home birth
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Have you informed your midwife about keeping your placenta?
*
Yes
No
Other
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Name of midwife or doula
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Have you thoroughly read through the information document provided via email?
*
Yes
No
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Have you ever tested positive for HIV/ Hep C/Hep B
*
Yes
No
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Have you smoked regulary through your pregnancy? If so, please state how many per day & when you stopped if you have stopped
*
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Do you have any allergies?
*
Please list
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Have you had or do you suffer from any of the following; Group B Strep, Herpes, Lupus, PUPPP, Rubella/Congenital Rubella?
*
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Please list any medications you are currently taking
*
Type N/A or None if applicable
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Please tick which products you would like to order
*
Simple Placenta Capsules
Steamed Placenta Capsules
50/50 Placenta Capsules
Courier fee Causeway/SWAH/Alnagelvin
Placenta Tincture
Placenta Essence
Framed Cord Keepsake
Homeopathic Remedies
Massage oil
Stretch mark oil
Balm
Cream
Placenta Print
Or please state a package below
Other
Would you like a FREE umbilical cord keepsake?
*
Yes
No
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Would you like some photos / videos of your placenta?
*
Yes
No
Can we upload anonymous pictures / videos of your placenta to our social media channels?
*
Yes
No
Other
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How did you hear about us?
*
I have read & agree to the term & conditions above
*
Agree
Disagree
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Please sign
*
Date
*
-
Day
-
Month
Year
Date
Submit
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