Client Pickup Appointment Request Form

Required Notice
Client Pickup Appointment Request Form
PLEASE READ BEFORE CONTINUING

All applicants must read this form in its entirety before submitting a request. Our form and pickup options have recently changed.

Butterfly Whisper requires a minimum of 30 days between each pickup request.

If a request is submitted that is less than 30 days from your previous pickup, your appointment will be rescheduled to the next available eligible date. You will receive an email notification with your updated pickup date.

Submitting this form confirms that you understand and agree to these policies.

Please complete each section carefully so our team can prepare your order correctly.
Yes, I understand and wish to continue.
Client Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CherokeePickensFloydAcworth AreaBartow
County
Please list the county you live in.
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email
example@example.com
Preferred Language (English, Español, فارسی)*
Total Number of People in Household*
Pregnancy
YesNo
YesNo
Pregnant women that are 20 weeks are more can receive a free Mother's gift box. This gift box includes some much needed essentials for mama and baby. Example of items that may be in the gift box: Baby swing, Carseat, pacifier, bottle, diapers, socks for mom, baby wash, hand lotion etc.

If you are interested in this gift box, please use the file upload below and upload your recent sonogram photo. The photo must list the members name and weeks pregnant.
Sonogram Photo or Birth Confirmation

Cancelof
Please list EVERY person living in your household INCLUDING yourself.*
Diaper & Wipes Needs
YesNo
Children Needing Diapers or Pull Ups*
YesNo
YesNo
Household Member*
Baby WashBaby LotionDiaper Rash Cream
Baby WashType option 2Type option 3Type option 4
Child ToothbrushChildren's 3 in 1 Wash and Shampoo
ShampooConditionerToothbrushSoap/Body Wash
ShampooToothbrushSoap/Body Wash
ShampooConditionerSoap/BodywashDeodorantToothbrushPads ThinPads ThickPanty LinersFeminine WipesShaving CreamShavers
ShampooConditionerSoap/BodywashDeodorantToothbrushPads ThinPads ThickTamponsPanty LinersFeminine WipesShaving CreamShavers
ShampooSoap/BodywashDeodorantToothbrushShaving CreamShavers
Hygiene Kit*
YesNo
Additional Needs (Available Only If In Stock)
The following items are only available if they are in stock.
YesNo
Which members need socks? Specify name, shoe size, and sex.*
YesNo
Which members in your household are in need of underwear? Specify their name, size, and sex.*
YesNo
Formula Brand*
Child needing formula.*
Pickup Appointment Time
Appointment- If you have an emergency, please mail trewis@butterflywhisperinc.com.*
Acknowledgment & Signature
Signature*

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Today's Date*

MonthDayYear
Date
By signing above, I certify that the information provided is true and accurate to the best of my knowledge. Providing false or incomplete information may result in delayed or denied services.
Should be Empty:

Required Notice

Client Pickup Appointment Request Form

Client Information

Pregnancy

Diaper & Wipes Needs

Additional Needs (Available Only If In Stock)

Pickup Appointment Time

Acknowledgment & Signature