Sacred Seasons Birth Order Form

Service Contract & Order Form

Thanks for choosing Sacred Seasons Birth! Just fill out the order form and service contract below, and be sure to send in your $150 non-refundable deposit right after submitting your form.
Contact Information

Share your contact details along with those of your support team. Make sure to include the address where your final products should be shipped.
Client Name *

First NameLast Name
As of today, how many weeks pregnant are you?*
If you haven’t established your gestational age yet, just give your best estimate as of now
When is your baby due?*

MonthDayYear
Client Email
example@example.com
Client Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Partner/Support Person’s Name*

First NameLast Name
Client Partner/Support Person's Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a doula or secondary support person?*
If you have a doula or a third individual that will be with you in the delivery room who can be responsible for the placenta, add their information here
Doula/Secondary Support Person’s Name *
Doula/Secondary Support Person’s Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate who should be included in the "Welcome" text thread*
You will receive a group text that will include you (the client), 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 progress and coordinating the pickup of your placenta.
How did you hear about Sacred Seasons Birth?*
If someone referred you, please provide their name so I can personally thank them!

Please read the important information below before filling out and submitting your form. If you have any questions, concerns, or need clarification, reach out to Kelli Stone at 940-230-6690 before sending in your order form.

Preparation

Once I’ve received your order form and the non-refundable $150 or $200 deposit, I will process your form, add you to the service schedule, send you a copy of the form along with an invoice, and send a welcome text message that includes you, me, and your support person(s) (if applicable). This chat thread will be used to keep me updated on your placenta’s delivery and shipping status. I highly recommend including at least one support person to ensure smooth and effective communication for everyone involved.

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.
Since many facilities have policies requiring the placenta to be removed from the premises within 60 minutes of delivery (though this time may vary), it’s a good idea for your support person to take the secured placenta to your vehicle until it can be brought home and stored in the freezer.

*Secured means the placenta is triple-bagged in the collection bags from your kit, placed in the provided cooler with two inches of ice beneath it and two inches of ice on top, and is safely in your possession or that of your designated support person.

The placenta should be placed on ice within 4 hours after delivery and can stay chilled, either on ice or in the refrigerator, for up to 72 hours before it needs to be frozen.

Order Form and Contract

Before you’re added to the service schedule and your placenta collection kit is sent, I’ll need the following.
- 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’s always best to arrange services as early in your pregnancy as possible, but I understand life happens. I’m happy to accept clients who are due any or have recently delivered, as long as the following conditions are met.
- The placenta was securely stored on ice within 4 hours after delivery. It was kept on ice or refrigerated for no longer than 72 hours, or placed in the freezer within that timeframe. The birth occurred less than a week ago.
Deposit and Itemized Invoice

A $150 non-refundable deposit is required when you submit your completed order form and contract, unless you need your placenta collection kit expedited. In that case, an extra $50 is added to cover rush shipping, making the total $200 due at submission. The $150 deposit goes toward your overall balance, secures your spot on the service schedule, covers your placenta collection kit with shipping, and includes return shipping of your placenta to Sacred Seasons Birth. Once I receive your order form, contract, and deposit, I’ll send you a copy of your order form along with your invoice.

Payment Options

A $150 non-refundable deposit is due when you submit your order form and contract (or $200 if you need the placenta collection kit rush shipped). You’re also welcome to pay the full balance upfront if you prefer.

Any remaining balance must be paid in full once the placenta is delivered and secured. If the final payment isn’t made within the specified timeframe, it may delay processing, the return of your placenta products, and could lead to an additional storage fee. Unless prior arrangements are made, the following applies:
- If I don’t receive the remaining balance within 72 hours of delivery and haven’t heard from you, I’ll consider your order form or contract null and void and take you off the service schedule.
- If you choose to encapsulate your placenta after the 72-hour window has passed, you’ll need to reach out to me to fill out a new order form, sign a fresh contract, and pay the remaining balance right away.
- If I get your placenta in the mail but haven’t received the remaining balance, you’ll have 72 hours from when I provide proof of receipt to send the full payment.
- If 72 hours pass after receiving your placenta without any communication or payment, a $75 storage fee will be added to your total balance.
- If after 14 days there’s no communication from you and/or the full balance, including the $75 storage fee, hasn’t been paid, your placenta will be disposed of and the contract will be considered null and void.
Payment plans are available upon request throughout your pregnancy and can be split into 2, 3, or 4 installments. Any remaining balance is due at delivery..

The following are the accepted payment platforms

Zelle: Kelli Stone 940-230-6690

Apple Pay: 940-230-6690

CashApp: $placentacapsules

As a small business, I don’t have a credit card processing machine, but in certain cases, I can accept credit cards through Stripe. If you need to pay by card, please reach out right away to confirm eligibility. A $15.00 processing fee will be added to your total to help cover the high costs that credit card companies impose on small businesses.

I can sometimes accept HSA cards and am always willing to try running them through Stripe. Depending on your HSA administrator, the payment might go through immediately, they might later ask you to justify the expense, or it could be declined right away. There’s no way to know until we try. If the card runs successfully but the company later requests justification, let me know and I’ll help you craft a response.

Refunds

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

Delivery of Products

Your order will be shipped in a USPS-insured package to the address you provide on the order form, unless stated otherwise.
- Your products will be shipped within 72 hours after I receive the placenta.
- Delivery usually takes 1–3 business days, depending on USPS closures, holidays, or bad weather.
- Once the package is handed over to USPS, the tracking number will be shared in the group chat.
- Once the tracking number is provided, I (Kelli Stone) am no longer responsible for any lost or damaged packages handled by USPS.
- Your package will be insured to the full amount you paid.
- If your package is lost or your items arrive damaged, it’s up to you to start and manage a claim with USPS for reimbursement. Be sure to follow all the steps and guidelines they provide, and complete everything within their specified time frame.
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

Contact Information

First Responders, Active Duty Military, Veterans & Medicaid

Permission to Post a Birth Announcement

Please read the important information below before filling out and submitting your form. If you have any questions, concerns, or need clarification, reach out to Kelli Stone at 940-230-6690 before sending in your order form.

Preparation

Order Form and Contract

Sacred Seasons Birth Order Form and Service Contract

Enter coupon