About Prenatal Sessions
Mom & Baby Sessions
Birth and Placenta Services
Placenta Encapsulation Intake Form
About Birth Services
Birth Doula Service
For Doula Clients
PRENATAL Placenta REMEDY INtake Form
Indicates required field
Partner's Phone Number
Estimated Due Date
What number pregnancy is this for you?
Where are you having your baby? (Name of Hospital, Birth Center, Home)
Have you experienced any complications during this pregnancy?
If yes, describe complications
Have you encapsulated your placenta before?
Does your care provider know you plan to encapsulate?
What is your preferred Method of Encapsulation, TCM or Raw Method?
Please list any medications your taking (Name, Dosage, Frequency)
Why are you choosing placenta encapsulation for birth and postpartum wellness?
Birth and Postpartum Choices
RAW or TCM Placenta Encapsulation Package $250 ( includes on-call service during your due month, pick up and delivery, capsules, placenta print, & umbilical cord keepsake)
Tincture (4 oz) $54 ** Highly recommended to preserve your placenta for future use
Placenta salve (4 oz) $33
Flower Essence/Essential Oil Postpartum Consultation (30 min) $54
Payment Options- Your payment in full is required to reserve your space in the Amma Prema calendar. Please be sure to specify who the payment is for on your check or paypal account if the name doesn't match.
Paypal- www.paypal.com by CC or debit (website) Pay to: email@example.com (You will need to add 3% to your total for paypal fees)
Check made payable to: Elaine Barr, and mailed to: 200 Stablegate Drive Cary NC 27513
Payment by check in person at Baby + Co. birth center, Cary, NC
Signature (You acknowledge this as your signature by typing your name below and agree to hire Amma Prema for Placenta encapsulation. You are eligible for a refund if for some reason your encapsulation is not possible or you cancel for any reason minus a $50 processing fee. Once your placenta has been picked up, no refunds will be given.)
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