Registration: Placenta Encapsulation

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PLACENTA SERVICES REGISTRATION

Cord Keepsake This intake should take you five short minutes to fill out.

Feel free to call Trisha at 619.527.2331 or email zoebellabirth@gmail.com with any questions you may have ahead of time. Please do not use the form below as an ‘inquiry’ as this takes up a space on my calendar for another mom.

To book Zoe Bella Birth for placenta services, please register before 37 weeks so Trisha can inform you about instructions specific to your birthing location. Last minute registrations are accepted but only if there is space. Book early if you want to ensure a spot and so you can be informed/prepared.

Once you fill out the registration, Trisha will email you within 24 hours with specific instructions and details.

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	CLIENT INFO
Mother's Name*:
Nickname:
Partner's Name:
Due Date*:
If you are planning a scheduled delivery (induction, cesarean), what is the estimated birthing date? This date may differ from your due date and it is understood it may change.
Where are you planning to give birth?*
Name of OBGYN or midwife*:
	Is your care provider aware of your plans to keep your placenta? NoYes If yes, what was their reaction?
Name of birth doula (if applicable):

	CONTACT INFO
Phone*:
Email*:
Home Address*:
City*:
Zip Code*:

	BABY INFO
Name of Baby:
Sex of Baby:

	MOTHER'S HISTORY
Please tell me about your upcoming birth. Check all that apply.*	This is my first baby.This is my second baby.This is my third/fourth/fifth/+ baby.I'm planning a vaginal birth.I'm planning a belly birth (c-section).I'm planning a VBAC.I'm planning an unmedicated birth.I'm planning on getting an epidural.
Ages of your other children, if any:
Do you have any infectious diseases, such as HIV/AIDS, Hepatitis, Herpes, Lyme?*	NoYes Please list any infectious disease(s) you have or may have.
Please list any complications that you are experiencing with this pregnancy:
Please list any medications you have been taking during this pregnancy.
I experienced the following after one or more of my previous births. Check all that apply.	Challenging physical recoveryChallenging emotional recoveryLow milk supplyBaby BluesPostpartum DepressionPostpartum AnxietyI had a great recoveryI'm not sure...Other:
	Is there anything you would like to share with me about your previous postpartum recovery/recoveries?
:	Why are you choosing to ingest your placenta? What benefits are you looking forward to?
Please add any additional questions/comments here.