Placenta/Cord Keep Sake Booking Form

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This form must be completed ahead of sending/accepting the placenta and/or Cord. By completing this form you are giving Every Birth Matters consent to use the Placenta/Cord for making a keepsake for you.

The cost of this service is: £125.

Please note that the Frame is not included. You will be given the option to include your frame and postage below.

Email *

Name *

Address (in full) *

Contact Number *

Expected Due Date of baby *

YYYY

Place of Delivery (home/hospital name/MLU name) *

Have you spoke to your midwife about wanting to keep your placenta/cord? If not please communicate in your birth wishes that you want to keep/take your placenta/cord home. *

yes

I will include this in my birth wishes/plan

Required

For our own protection, we MUST have an honest answer to the following question. Have you ever tested positive for HIV, Hepatitis B or Hepatitis C? *

I am sending Every Birth Matters *

Full Placenta and Cord

Placenta only

Cord only

Required

I understand that i am to package the cord as directed by the information leaflet that will be sent to me by Every Birth Matters.

I understand that Every Birth Matters will do what they can with the cord and this is dependent on length. This will be communicated with me upon receipt of the placenta/cord.

I understand and agree

I wish to purchase;

You will be sent a invoice and payment details separate upon receipt of this form. Payment is via bank Transfer or Paypal. Tick all that apply to you

Placenta KeepSake/Jewellery £125

Cord KeepSake £125

Postage & Package RETURN £10

Boxed Frame £10

Free Scan Picture - If you are choosing the Boxed frame option please do send a scan picture for the back ground this is free of charge just include in your parcel to Every Birth Matters

Required

I would like to pay by; *

Bank Transfer

Paypal

I understand then when i submit this form, I will receive a copy as my receipt and Every Birth Matters will contact me directly via email. *

I agree

I understand by ticking I agree that I am consenting to sending my Placenta/Cord to Every Birth Matters. I understand Every Birth Matters is not responsible for the condition of the Placenta/Cord.

I must send the parcel 24 hour delivery.

I agree

Required

A copy of your responses will be emailed to the address you provided.

Submit

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