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Name
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Email
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Phone
How did you hear about us?
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Select one option
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Other
If ‘Other’, please share:
Are you currently pregnant, or hoping to be soon?
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Yes, I am currently
I'm hoping to be in the near future
No
What is your Estimated Due Date? (YYYY-MM-DD)
Where are you planning on giving birth?
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Home
Hospital
Birth center
If hospital or birth center, please let us know which one?
Name of Planned Midwife or Physician?
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Which encapsulation method do you prefer?
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Raw Method
TCM Method
What services are you interested in? (Please check all that apply.)
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Just the Basic Placenta Package (capsules only)
Placenta Tincture
Placenta Salve
Placenta Truffles
Placenta Cookies
Other
If other, please explain:
Which, if any, other services are you also wanting to book at this time? (Belly binding, Postpartum Care, etc.)
Have you had any health concerns with this pregnancy? If yes, please explain:
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More specifically, have you ever been diagnosed with any of the following before or since this pregnancy/birth?
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HIV
Gonorrhea
Syphilis
Chlamydia
Hepatitis B or C
Are you taking any medications or supplements (other than Prenatal Vitamins)? If so, please list below:
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Have you done/used any of the following during this pregnancy?
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Smoking or Vaping
Alcohol
Recreational Drugs
Other
If yes, please explain: (Please include frequency & date of last use.)
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Anything else you think I may need to know? …or anything that you have questions for me about?
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Soluna
July 2, 2025
Uncategorized
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