Name
*
First Name
Last Name
Email Address
*
Phone Number
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Estimated Due Date/Birth Date
*
Have you had your baby yet?
*
Birthing location (name and address)
*
What services are you interested in?
*
If you selected a print, please choose style:
Colors 2 max - please see wilton colors chart or select two basic color wheel colors
How are you planning for the placenta to get to us? -select all that apply
*
We need placenta to be placed into refrigerator or a cooler with ice immediately after birth. AND we would like to pick it up the same day of birth (next day after night birth). Otherwise placenta should be frozen as soon as possible. Outside 25 miles from our office will accrue an extra travel fee.
How do you want your placenta products returned
*
Please check any of the following conditions that you have been diagnosed with during this pregnancy. (please see instructions for more information)
*
As an encapsulator, it is not our place to say if you SHOULD or SHOULD NOT encapsulate your placenta. If you have a diagosis, it is up to you to do your own research and make the best informed decision for you and your family. IF you have any questions on where to look for information feel free to inquire with us and we may know of places you can look-not guaranteed.
Baby's Gender
Did you click yes to any of the above listed options? Or do you have a condition that is not listed? Please give us more information and we will contact you to discuss this.
Do you have any allergies? (please note that while I do sanitize and sterilize my prep area and instruments, There may be nuts, dairy and gluten in the same building.)
*
Cord Keepsake? (Free)
*
By submitting this form, I understand that I am requesting placenta services and an invoice with the service contract, placenta instructions will follow shortly. Time in our calendar will be reserved for your due date once we have received the contract back via email and fee has been paid
*
IF for some reason our calendar is full or we are not accepting new clients that month, we will contact you. If you live outside of the Denver Metro area, please contact us at 720-295-2492 to see if we service your area.
For those requesting placenta services, please go to fill out the
Click: Placenta Services Waiver and Release Form
We will send a invoice out to you within 2 business days.
Or
If you are not currently submitting an order, we will follow up with you shortly.
