Name
*
First Name
Last Name
Phone Number
*
(###)
###
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Email Address
*
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Partner's Name
First Name
Last Name
Partner's Phone Number
(###)
###
####
Place of Birth
*
If you plan to give birth at a home address that's different than your mailing address, or if your place of birth is not an option above, please provide it here:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Midwife or Doctor Name
*
Estimated Due Date
*
mm/dd/yy
MM
DD
YYYY
Please list any allergies.
Please choose your placenta package-payment is due the day your capsules are delivered to you.
Premier packages come with pick up service. If a basic package is chosen the placenta will need to be dropped off by a friend or family member at the kitchen.
DELIVERY: The majority of packages are hand delivered. If you live in an outlining area of Austin (Elgin, Dripping Springs, Spicewood, Bastrop) there may be an additional hand delivery fee of $20.00 or we can ship the package overnight to you without an extra fee. This will be discussed with you after your reservation is received. Payment is NOT due now. It is due when you receive your package.
How would you like your placenta prepared?
*
Traditional Chinese Medicine Method of Encapsulation
Raw Method of Encapsulation
Raw Cubes Only for Smoothies
First Week Raw Cubes - Remainder Traditional Method
First Week Raw Cubes - Remainder Raw Method
The amniotic membrane which covers the baby and holds the amniotic fluid would normally be discarded when your placenta is processed. We are partnered with a lab in Round Rock that can make wound care bandages out of this membrane for patients with non-healing wounds such as burn victims and diabetic patients. These bandages are FDA-approved. If we donate this membrane, you will receive $50.00 off your placenta package.
*
Would you like to add a placenta tincture?
*
Would you like to add an herbal product?
*
If yes, please indicate which product(s) you would like to purchase:
If yes, would you like your placenta added to your product(s)?
Would you like a keepsake placenta print? $10.00
*
Placenta prints are done using just the blood from the placenta to make the print. No paint or dye is used.
If you have ordered a placenta print- would you like us to frame it? Framing is $30.00
How did you hear about Hill Country Placentas?
*
If you were referred by someone please let me know who that was so I may thank them.
