Client Sign-Up Form

First Name: (required)

Last Name: (required)

Type of Client: (required)

Local Client (within 40 miles of Wentzville, MO) Extended Mileage Client (40-60 miles of Wentzville, MO) + $25 Travel Fee Shipping Client (US Only) + $50 Shipping Kit/Program Cost

Email: (required)

Phone Number: (required)

Street Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Baby's Estimated Due Date: (required)

Planned Delivery Location: (i.e. name of hospital, birth center, home)(required)

Preferred Method of Contact: (required)

Phone Call Text Email

Package Selection: Package options are listed on bottom of this page.(required)

Basic $297: Capsules / FREE Umbilical Cord Keepsake Standard $347: Capsules / 2 Keepsakes / 1 Tincture Premium $397: Capsules / 2 Keepsakes / 2 Tinctures / 2 Salves I am signing up to hold my space on your due date calendar and will decide at a later date. $149: Keepsakes ONLY

Would you like pictures of your placenta and/or your encapsulation process? No added cost.(required)

No Photos (keep that stuff behind the scenes) Placenta Photos Only Placenta Photos and Process Photos

Umbilical Cord Keepsake Preferences: Included in all packages. Photos of options are listed on bottom of this page. No added cost. (required)

Can be updated at a later date if you’re waiting on baby’s gender to be known.

Tree of Life Placenta Print Preferences: Included in standard & premium packages. Photos of examples are listed on bottom of this page.

I opted for Basic Package, does not include tree of life print. Natural Print Watercolor Painted Print*

*No dyes, food coloring, or paints used on the placenta. Placenta is covered with plastic/saran wrap and the vessels are traced individually.

If watercolor tree of life chosen, enter color preferences below: 2-3 colors are best.

Can be updated at a later date if you’re waiting on baby’s gender to be known.

If referral, event, or other please specify:

Would you like to add another contact person to your file? (Helpful for local clients if a support person will be aiding in pickup/dropoff.)

Yes No

If yes, additional contact person name:

If yes, additional contact person contact information:

If yes, additional contact personal relation ship: (i.e. husband, doula, other family member):

Gift Certificate? Referral Code? Enter the code below:

Anything else you'd like me to know? (allergies, sensitives, variations to standard preparations, news about baby, etc.)


Basic Package – $297	Standard Package – $347	Premium Package – $397
Includes: – Completed Capsules – Free Umbilical Cord Heart – Printed Info – Text/Call/Email Support from Certified Encapsulator	Includes: – Completed Capsules – Umbilical Cord Heart – Tree of Life Print – 1 Tincture – Printed Info – Text/Call/Email Support from Certified Encapsulator	Includes: – Completed Capsules – Umbilical Cord Heart – Tree of Life Print – 2 Tinctures – 2 Placenta Salves – Printed Info – Text/Call/Email Support from Certified Encapsulator

Natural	Pearl Coated Pink	Pearl Coated Blue
Metallic Gold Plated	Metallic Rose Gold Plated	Metallic Silver Plated