Registration for Placenta Encapsulation

Thank you for choosing us to Encapsulate your placenta.

Encapsulation Registration

First Name*

Last Name*

Guess Date/ Estimated Due Date*

I will be using Traditional Chinese Medicine method to encapsulate my placenta.

Traditional Method

Choose a method for pick up or delivery*

I will deliver the placenta to Stephanie.
I want Stephanie to pick up and drop off the placenta.
I would like to discuss with Steph to make other arrangements for pick up and delivery.

We charge $.50 a mile from Bemidji, MN to pick up and deliver the placenta. Pick up in Bemidji is included in the cost. Unless other arrangements are made with Steph.

E-mail*

Phone*

Pick Up and Delivery Address*

Address Line 2

City*

State*

Zip Code*

Are You Planing a Home or Hospital Birth?*

Home
Hospital

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