Placenta Contract | Midwife in DFW

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Heritage Birth and

beyond

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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

"Children are a heritage of the Lord, and the fruit of the womb is His reward"
Psalm 127:3

midwife near fort worth

Christina Evans, BSM, LM, CPM, CBS

HeritageBirthAndBeyond@gmail.com

Midwife, Homebirth, Waterbirth, Breastfeeding and Lactation, Placenta Encapsulation, Postpartum Care

Currently serving Fort Worth, West DFW, Weatherford, and parts of Wise, Parker, Tarrant County and more!

*All photos are personally owned, or otherwise credited, and used with permission.

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