Pay By Check Encapsulation Agreement

Placenta Encapsulation Agreement (NP)

First Name

Last Name

Cell Phone

Alternate Phone

Street Address

City

State

Postal / Zip code

Note: $20 mileage fee applies to clients to Kyle, Dripping Springs, Manor, Jonestown, Georgetown, Hutto, Leander, Lago Vista, Lakeway, Elgin, Spicewood, Bee Cave, and other towns not listed that are 15+ miles from Central Austin.

Estimated Due Date/Baby's Birthday

Name of Hospital/Birth Center/Home

Name of Doctor/Midwife

Placenta Encapsulation Fee (note a 4% processing fee is included in the price)

Single Placenta - $234

Twins Placenta - $312

I agree to the terms and conditonsView terms and conditions

Pickup Agreement

I understand that my placenta will be picked up during daytime hours (8am-8pm) and I will not call/text the doula line overnight. I understand that I can notify ATX Doulas overnight by email only at placentas@atxdoulas.com

Your Signature