Placenta Encapsulation Inquiry

We look forward to supporting you with your placenta encapsulation!

Please take a moment to read our Release of Liability, then fill out the form below completely to be sure we have all the information we need.

Name

First Name

Last Name

Phone

(###)

###

####

Estimated Due Date

YYYY

Where do you plan to give birth?

Home Address

Please type the entire address of where you would like your placenta capsules delivered so we can calculate any pick up and delivery fees.

Payment Method

Cash

Check

PayPal

Venmo

I have read and understand the Vitality Home Birth PLACENTA ENCAPSULATION AGREEMENT AND RELEASE OF LIABILITY.

*If not, please see link at the top to go back and read.*

Yes, I have read, understand and release liability.

No, I have not read or do not agree.

How did you hear about Vitality Home Birth?

Alison Fischman, CPM, LM