Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Partner's Name
First Name
Last Name
Partner's Phone Number
Estimated Due Date
mm/dd/yy
MM
DD
YYYY
Place of birth
*
Midwife or Doctor Name
*
Please list any allergies.
Please choose your placenta package-payment is due the day your capsules are delivered to you.
Premier packages come with pick up service. If a basic package is chosen the placenta will need to be dropped off by a friend or family member at the kitchen.
DELIVERY: The majority of packages are hand delivered. If you live in an outlining area of Austin (Elgin, Dripping Springs, Spicewood, Bastrop) there may be an additional hand delivery fee of $20.00 or we can ship the package overnight to you without an extra fee. This will be discussed with you after your reservation is received. Payment is NOT due now. It is due when you receive your package.
How would you like your placenta prepared?
*
Traditional Chinese Medicine Method of Encapsulation
Raw Method of Encapsulation
Raw Cubes Only for Smoothies
First Week Raw Cubes - Remainder Traditional Method
First Week Raw Cubes - Remainder Raw Method
Would you like to add a placenta tincture?
*
Would you like to add an herbal product?
*
If yes, please indicate which product(s) you would like to purchase:
If yes, would you like your placenta added to your product(s)?
Would you like a keepsake placenta print?
*
Placenta prints are done using just the blood from the placenta to make the print. No paint or dye is used.
Are you interested in birth or newborn photography?
*
How did you hear about Hill Country Placentas?
*
If you were referred by someone please let me know who that was so I may thank them.
Cancellation policy agreement.
