Houston Placenta Services Booking Form

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Name Name First Last
Phone Phone - ### - ### ####
Birthing Partner's Name Birthing Partner's Name First Last
Birthing Partner's Phone Number Birthing Partner's Phone Number - ### - ### ####
Email
Estimated Due Date: Estimated Due Date: / MM / DD YYYY
Are you scheduled for a ceserean section?

Are you scheduled for a ceserean section? 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
Houston Placenta Services 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
Houston Placenta Services 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 Tincture's would you like to order?
Healing Salve, 4oz $45

Healing Salve, 4oz $45 Yes No How many Salve's 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