Born Free Birthing - Placenta Services Booking Form

1Placenta Services > 2Placenta Agreement of Services > 3Payment
Name Name First Last
Phone Phone - ### - ### ####
Birthing Partners Name Birthing Partners Name First Last
Birthing Partners Phone Birthing Partners Phone - ### - ### ####
Email
Estimated Due Date Estimated Due Date / MM / DD YYYY
Are you booked for a cesarean section birth ?

Are you booked for a cesarean section birth ? Yes No
Name of Care Provider (OBGYN/Midwife) Name of Care Provider (OBGYN/Midwife) First Last
Full name and address of the birthing facility where I will be picking up the placenta from. Full name and address of the birthing facility where I will be picking up the placenta from.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Address, where I will be delivering the placenta products. Home Address, where I will be delivering the placenta products.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I offer an overnight shipping services for the delivery of finished products, would you like to take advantage of this service? Finished products for bookings outside a 40 mile radius from Kingwood Texas will automatically be shipped.

I offer an overnight shipping services for the delivery of finished products, would you like to take advantage of this service? Finished products for bookings outside a 40 mile radius from Kingwood Texas will automatically be shipped. Yes, please arrange for my finished products to be shipped to my home. (excluding apartments and PO Boxes) No, I wish for you to deliver my finished products.
Method of Encapsulation: $285
Born Free Birthing is professionally trained in both the Raw Start and the Traditional Method (based on the Traditional Chinese Method where the placenta is steamed before being dehydrated). Please see my website for definitions and descriptions of both methods.

Method of Encapsulation: $285
Born Free Birthing is professionally trained in both the Raw Start and the Traditional Method (based on the Traditional Chinese Method where the placenta is steamed before being dehydrated). Please see my website for definitions and descriptions of both methods. Raw Start - $285 Traditional Method - $285
Placenta Tincture (Highly Recommended), 4oz $45

Placenta Tincture (Highly Recommended), 4oz $45 Yes No How many tinctures would you like to order?
Healing Salve, 4oz $45

Healing Salve, 4oz $45 Yes No How many salves would you like to order?
Include complementary Placenta Print and (natural, unpainted ) Cord Keepsake.

Include complementary Placenta Print and (natural, unpainted ) Cord Keepsake. Yes No
Brush the Cord Keepsake with Shimmering Gold Coating. $15

Brush the Cord Keepsake with Shimmering Gold Coating. $15 Yes No
Mama's Postpartum Healing Herbal Bath, 3 bags-$30

Mama's Postpartum Healing Herbal Bath, 3 bags-$30 Yes No
Would you like information on my 5 week HypnoBirthing childbirth preparation class?

Would you like information on my 5 week HypnoBirthing childbirth preparation class? Yes, please! No, thank you!
Price $ Dollars . Cents
A non-refundable retainer of $75 is required in order to secure your spot on my calendar. The remaining balance is due upon pick up of the placenta. Please contact me as soon as you have submitted this contract if you would rather pay your retainer by cash or check.