Ridge Meadows Doula Services

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September 29, 2016 · Leave a Comment

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Categories : Client Resources

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Doula Services Request Form

Name *
Phone *
Email *
Where are you planning on delivering? *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
What is your estimated Due Date? *
Are you interested in any additional services?
Prenatal EducationPostpartum Doula SupportPlacenta Encapsulation
Who is your care provider? *
Why do you want a Doula? *
Have you gave birth before? *
If you are comfortable, please share a little about those experiences
Are you a repeat client?
YesNo
How did you hear about Ridge Meadows Doula Services? *

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Placenta Encapsulation Request Form

Name
Phone
Email
Partners name
Partners phone number
Estimated Due Date
Where are you Delivering? What is your address for placenta capsules to be dropped off?
Name of Care Provider
How did you hear about RIDGE MEADOWS DOULA SERVICES?
Method of Encapsulation Preparation
Please select type of package you are interested in
$200 Drop off and Pick up provided by you$225 pick up and drop off from the encapsulator
Additions
tincture $40 for 4oz droppercolor print $40 for acrylic colormothers broth $15 (TCM only)Placenta Smoothie $35
Are you interested in more information regarding
Childbirth Education ClassesBirth DoulaPostpartum Doula
A $50 non refundable retainer is required to hold your spot, please choose payment method:
Email Money Transfer (preferred)checkcash
Are you on any medications? if so, what medications?
My placenta does not contain any communicable diseases such as Hep B, Hep C, HIV or Aids (please initial)
My care provider and I will determine that my placenta is healthy and suitable for consumption (please initial)
I will not hold Nicole Chambers or RIDGE MEADOWS DOULA SERVICES responsible if my placenta is accidentally damaged during the process or if the processing does not result in my ability to consume it (please initial)
Nicole Chambers does not determine whether my placenta is suitable for consumption and makes no guarantee of my personal results from the consumption (please initial)
Please sign (type) your name
Date signed

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Childbirth Education Request Form

Name
Phone Number
Email Address
Estimated Due Date?
Name of Care Provider
Where are you planning to birth?
How did you hear about RIDGE MEADOWS DOULA SERVICES?
What are you hoping to cover in a Childbirth Education Class?
Are you interested in any additional information?
Birth DoulaPostpartum DoulaPlacenta EncapsulationParenting Support

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