Placenta Remedies Order Form

Placenta Remedies Order Form

Name:*
Email Address :*
Mobile Telephone Number:*
Address (for delivery of the placenta collection kit):*
Baby's Estimated Due Date:
Remedies Requested (Tick all that apply):
- Standard Dehydrated Placenta Capsules (£210)
- Steamed & Dehydrated Placenta Capsules (£210)
- Placenta Tincture - raw or dehydrated (+£45)
- Placenta Essence (+ £30)
- Fresh raw placenta smoothie (+£10)
- Smoothie, Essence &/or Tincture without capsules (£100 + cost above)
- Framed placenta picture (digital image free)(+£15)
Location of Birth Planned (e.g. Hospital Name / Birth Unit Name / Home etc):*
If other selected above, please tell me where you are planning to have your baby::
Any other comments::

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