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Placenta remedies booking form
About you:
First name
Last name
Email
Phone
Address
Birth partners name
Birth partners phone number
Your Birth:
Your due date
Name of your midwife/midwifery team
Address of planned pace of birth
Midwives phone number
Planned place of birth
Home
Birthing Unit
Hospital
Medical information:
Have you ever been tested positive for HIV / Aids, Hepatitis B or Hepatitis C?
Yes
No
Have you ever had an Active Genital Herpes Outbreak?
Yes
No
Have you ever tested positive for Group Strep B?
Yes
No
Have you ever had a blood transfusion?
Yes
No
Do you have any allergies?
Yes
No
Are you on any medication? If so please tell me what in the box below.
Yes
No
Do you smoke?
Yes
No
Are there any other medical information that may be relevant?
Choose you remedies:
Humble Pleasures: Simple capsules, smoothie and tincture $300
Simple capsules $250
50/50 mix of simple and steamed capsules $290
Spoilt for choice: 50/50 capsules, smoothie, tincture, wonder balm, face oil $400
Steamed capsules $280
Full placenta smoothie pack $180
Choose you extras:
Smoothie $49
Dried cord keepsake $free
Placenta tincture $90
Placenta wonder balm $49
Placenta face oil $45
Other:
Do you want any of your placenta returned to you for burial?
No thank you
Please return the amniotic sac for burial
Please return the sac and cord for burial
Please return the sac, cord and 1/4 of the placenta for burial
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