Nestle & Bloom | Booking Request for Placenta Remedies

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- Placenta Products
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BOOKING REQUEST

Please fill in the booking form and complete the consent section to arrange your service. By completing this form, you consent to Nestle & Bloom’s Service Terms & Conditions.

Name

Email

Phone number

Home Address

Estimated Due Date

Collection Hospital

Do you have a birth support person we should contact to arrange placenta collection? (If yes, please provide name and contact details)

Does your doctor/midwife support your decision to encapsulate your placenta?

Yes No

How many times have you birthed?

Is this a twin pregnancy? (Please note extra charges may apply for twin placentas)

Yes No

Are you having a caesarean or induced birth? (If yes, your delivery date is fixed, rather than an "estimated due date")

Yes No

Do you consent for photos to be taken throughout the process of your placenta encapsulation?

Yes No

Would you like Nestle & Bloom to email or text you photos of your placenta?

Yes No

Have you ever tested positive for HIV/AIDS, Hepatitis A, B, or C, or Syphillis?

Yes No

Are you aware of any other bloodborne diseases that you are a carrier for? (Please provide details)

Have you ever tested positive for GBS?

Yes No

Where did you hear about Nestle & Bloom?

Please select you service (If there is a special, these prices will be changed in the invoice)

Would you like a complementary cord keepsake?

Yes No

I consent that all the above information is accurate and true. If for any reason the above information changes, I will notify Natalie Johanik via email or phone as soon as practicable, and before collection of my placenta.

I consent

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