Placenta Remedies Client Booking Form

1
Client Name* This field is required
First Name
Last Name
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2
Client Date of BirthPlease enter your date of birth here
Date
Year
Month
Day
Date
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3
Estimated Due Date* This field is requiredPlease enter your EDD here
Date
Year
Month
Day
Date
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4
Birth Number?* This field is requiredPlease enter how many babies you have birthed previously:
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5
Partner's Name
First Name
Last Name
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6
Mobile Number* This field is required
Home
Mobile Phone Number
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7
Partner's Mobile Number
Home
Mobile Phone Number
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8
Email* This field is required
example@example.com
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9
Address* This field is requiredHome address
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Enter
10
Name and Address of Planned Place of Birth* This field is requiredPlease indicate if you are planning a home, birth centre or hospital birth
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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11
Name and Contact details of your Midwife or Doula (If applicable)
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12
Have you informed your Midwife about keeping your Placenta?(Not essential)
YESNO
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13
Have you ever tested positive for Hep B?* This field is required
YESNO
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14
Have you ever tested positive for Hep C?* This field is required
YESNO
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15
Have you ever tested positive for Lupus?* This field is required
YESNO
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16
Have you ever tested positive for Creutzfeldt–Jakob disease (CJD)?* This field is required
YESNO
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17
Have you ever tested positive for HIV?* This field is required
YESNO
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18
Have you ever tested positive for Group B Strep (GBS) or Rubella during THIS pregnancy?* This field is required
YESNO
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19
Have you smoked regularly during this pregnancy?* This field is requiredPlease answer this question honestly, it is for your own safety
YESNO
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20
Do you have any allergies?* This field is requiredIf yes please list below, if none known state "None"
List allergies here
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21
Do you have any other medical conditions?* This field is requiredIf yes please list:
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22
Are you on any regular medications?* This field is requiredIf yes please list below:
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23
Please indicate which of the below you wish to book:* This field is requiredAll services automatically include loan of the Placenta Chiller Pack, personal collection with temperature controlled FSA approved equipment from either the Hospital, Birth Centre or your home within 24 hours of notification receipt. I always aim to collect Placentas within 4-12 hours latest though. All orders are aimed to be processed within 24-48 hours of collection. All orders come with Cord Keepsake in organza bag as standard unless requested otherwise: If you are purchasing a package, please indicate which type of capsule you would like created in this answer:
Steamed TCM Capsules £200 (£0 if buying as a package)
Simple Capsules £200 (£0 if buying as a package)
50/50 Capsules £250 (£0 if buying Ultimate Luxury package)
Personalised delivery of chiller pack and discussion £150
Immediate collection (El C/S only) £100 (subj to availability)
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24
Extra ServicesPlease indicate below (if any) of the extra products you wish to purchase:
Placenta Essence 300ml (Includes Mini Dropper) £55
Homeopathic Remedies 30c & 7c (Dispatched by Homeopathy, postage included) £60
Framed Cord Keepsake £40
Ultimate Luxury Package £530
Calm and Uplift Package £395 (£50 extra if 50/50 caps)
More for Mum £320 (£50 extra if 50/50 caps)
Bonding for Baby £265 (£50 extra if 50/50 caps)
A Little Extra Package £250 (£50 extra if 50/50 caps)
Facial Oil 50ml £65
Whipped Body Cream 200ml £55
Calm and Soothe Baby Massage Oil 100ml £35
Soothing Balm 100ml £35
Placenta Tincture 300ml (Delivered 6 weeks after prep, includes mini dropper) £75
Placenta Print £10
To be purchased alongside capsules only
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25
* This field is requiredPlease view the T&Cs, Privacy Policy and Info guide from PRN here. By selecting this box you also consent to The Placenta Pro contacting you via the information provided in order to discuss your booking:
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26
Signature* This field is required
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