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Heritage Birth and
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MEET CHRISTINA
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Please complete this form to book
placenta services
First name
Last name
Phone
Partner's name
Partner's phone
Estimated Due Date
Email
Street Address
Street Address Line 2
City
Postal / Zip code
Birth location
Home
Birth Center (specify below)
Hospital: (specify below)
Other: (specify below)
Address of birth location
Name of OB / midwife / other
Any complications this pregnancy?
How did you hear about placenta services?
Have you encapsulated in the past?
Why have you chosen to use your placenta?
To support healing
To support hormone shifts
To support lactation
To support energy levels
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