Booking form

Full name
Mobile phone
Partner's name
Partners Mobile phone
Address
Email
Expected due date
Birth Location—Please choose an option—HospitalHome birth
Name & Address of Hospital
Have you informed your OBGYN/midwife about keeping your placenta? —Please choose an option—YesNo
Have you read thoroughly through the document titled ‘PRN Information Guide for Expectant Mothers'? —Please choose an option—YesNo PRN Information Guide for Expectant Mothers

Have you tested positive for Group B Strep (GBS)? (If you are positive for GBS then as per our FSMS we can only provide Steamed not simple Caspules)

Please note that if you have tested positive for any of the following, we cannot process your placenta. HIV, Hepatitis B, Hepatitis C

Where did you hear about placenta encapsulation/Jellies?
Why are you interested in placenta services?

PLEASE TICK THE SERVICE(S) THAT YOU REQUIRE

Simple Capsules - €250
Clear caps (vegetarian)Berry Flavoured add €20
Steamed Capsules - €250
Clear caps (vegetarian)Berry Flavoured add €20
Placenta Jellies & 100ml Tincture €280
Strawberry FlavouredBubble-gum Flavoured
Capsules & Jellies €350
SimpleSteamedStrawberryBubblegum
Tincture
100ml - €50300ml - €80
Essence
100ml - €40
Homeopathy
€60
Placenta Oil
50ml - €60
Would you like an umbilical cord keepsake?
Yes - Free keepsakeYes - Simple framed keepsake €20Yes - Detailed framed keepsake €30No thanks

PLEASE CONFIRM THE FOLLOWING

You have/will inform your OBGYN/Midwife that you are keeping your placenta
Yes
Do you intend to Breast?
YesNo
Balance of payment will be paid on collection of your placenta
Yes
You have read and agree to our Terms and Conditions
Yes
By submitting this form you agree that all the information you have given is correct and to the best of your knowledge.
Yes
By using this form you agree with the storage and handling of your data by this website
Yes
You agree to follow all the instructions that will be delivered with your cooler pack, ensuring the proper care and safe storage of your placenta before collection
Yes
PLEASE NOTE THAT TO COMPLETE YOUR BOOKING, A NON-REFUNDABLE DEPOSIT OF €50 IS REQUIRED, THIS CAN BE PAID IN OUR SHOP HERE. Once received, I will confirm your booking by email.