PLACENTA SERVICES CLIENT INTAKE FORMS Name First Name Last Name Email Due Date MM DD YYYY Payment Due Date (37 weeks) MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Location of Birth Phone Number (###) ### #### Backup Phone Number (###) ### #### Package Basic ($250) Upgraded ($275) Premium ($325) Luxury ($375) Mothermade Magic ($150) Method of Processing Steamed True Raw Modified Raw Upgrades Herbal Capsule Boost ($25 each) Framed Placenta Print ($50) Placenta Print ($20) One Dozen Placenta Chocolates ($30) Birth Planner Access ($10) Additional Tincture ($20) Steam Boost ($10) Herbal Capsule Boosts ($25 each) Ashwagandha Maca Matcha Green Tea Moringa Ginger + Turmeric Chlorella Red Raspberry Leaf Package Total $ Travel Fee (over 1 hour from Glendale) Yes No Notes I would like to be tagged on social media Yes No Instagram name How did you find me? Thank you! PLACENTA SERVICES CONTRACT SIGN CONTRACT LIABILITY WAIVER SIGN WAIVER
