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thesussexdoula@gmail.com
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Placenta Remedies Booking Form
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About
Nurture
Massage and Reiki
Gatherings and Classes
Birth Art Mandala and Belly Painting
Nourish
Shop
Placenta Remedies
Placenta Remedies Booking Form
Doula
Blog
Contact
Placenta Remedies Booking Form
Gemma Harvey Certified Placenta Remedy Specialist
Download Terms and Conditions
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Email
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Expected Due Date
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Planning Hospital or Home Birth?
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Hospital
Home Birth
Name and address of Hospital:
Name and contact of your midwife (antenatal) and doula:
Have you informed your midwife about keeping your placenta?
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No
Have you read thoroughly through the document titled ‘PRN Information Guide for Expectant Mothers'?
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No
For our own protection, we MUST have an honest answer to the following questions
Have you ever tested positive for HIV, Hepatitis B or Hepatitis C?
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Yes
No
Have you smoked regularly during pregnancy?
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Yes
No
Where did you hear about placenta encapsulation?
Why are you interested in placenta remedies?
Services
Product Name
Options
Home Visit
Hospital/Home Collection*
Steamed TCM Placenta Capsules
Simple Placenta Capsules
*All placenta’s are collected by hand in a cooler bag and stored on ice during transit
Options
Raw Placenta Smoothie
Placenta Tincture
Placenta Cream
Placenta Print
Homoeopathic Placenta Remedies 30c & 7c
Placenta Essence
Placenta Essence (ordered with capsules)
Placenta Balm
Umbilical cord heart keepsake (no extra charge)
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I have read and agree to the terms and conditions
The Terms and conditions and available from the link at the top of this form.
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