Placenta Encapsulation Contract

Complete this form & payment to book your encapsulation services by The Grosse Pointe Doula, LLC

1Client Information > 2Limitations and Disclaimers > 3Preferences > 4Fees > 5Review Your Contract > 6Payment
Name Name First Last
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Estimated Due Date or Scheduled Induction/Cesarean Date Estimated Due Date or Scheduled Induction/Cesarean Date / MM / DD YYYY
Birthing Location
If birthing at Troy Beaumont, all releases from OB/Midwife and Pediatrician MUST be completed before agreeing to a time to pick up your placenta. A $50 travel fee will be included if a second trip for pick up is required due to releases not being completed or other hospital policy circumstances preventing placenta release at initial pick up.

If birthing at Troy Beaumont, all releases from OB/Midwife and Pediatrician MUST be completed before agreeing to a time to pick up your placenta. A $50 travel fee will be included if a second trip for pick up is required due to releases not being completed or other hospital policy circumstances preventing placenta release at initial pick up. I Agree Not Applicable - Not birthing at Troy Beaumont
Name of provider/practice (OB or midwife group name)
Referred by:
$0

Total
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