Printable Client Intake Form

 

If you are having trouble filling out the online form, feel free to use these questions. You can copy and paste and email the answers to atlantaplacenta@gmail.com or text a picture to 678-744-9766.

Clients Name ::
Clients Estimated Due Date ::
Home Address & City ::
Phone Number ::
Alternate contact name and phone number: ::
Email Address ::
Is this your first pregnancy? ::
How has this pregnancy gone so far?Any complications/ health concerns? ::
Are you taking any medications during this pregnancy, other than prenatal vitamins? ::
Do you have any specific health issues that could place anyone at risk who comes into contact with your placenta? ::
Do you have any allergies? ::
Where are you birthing? ::
Who is your Care Provider? ::
Have you talked to your care provider about keeping your placenta? ::
What was their reaction? ::
Why have you chosen to use your placenta? ::
Which package have you chosen? (circle one):: Basic     Booster    Works
Would you prefer your placenta to be prepared raw or TCM? (circle one):: RAW     TCM       not sure, please help me decide
Would you like the herbs to be included with half of your placenta (no additional charge)? :: yes     no
Are you a vegetarian? (I have veggies capsules available.) :: yes      no
If you would like a smoothie, is there anything you would prefer in your smoothie? ::
Where and when would you like the placenta to be picked up? ::
Are you having a boy or girl? ::
How did you hear about us? ::
How will you be providing a copy of your blood work? ::
If “other”, please specify. ::
Would you like to add on any a-la-cart items? ::