Belly Binding Agreement

Please take a few moments to fill out the information below to reserve belly binding services.

Estimated Due Date or Delivery Date Estimated Due Date or Delivery Date / MM / DD YYYY
Name Name First Last
Phone Numer Phone Numer - ### - ### ####
Email Address
Partner's Name Partner's Name First Last
Partner's Phone Number Partner's Phone Number - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Birth Location
Do you have any allergies?

Do you have any allergies? No Yes. Please list: Yes. Please list:
Any complications during this pregnancy?

Any complications during this pregnancy? No Yes. Please list: Yes. Please list:
Are you planning to have or have you ever had a cesarean birth?

Are you planning to have or have you ever had a cesarean birth? No Yes
Why have you chosen Belly Binding Services?
How did you hear about my services? (Please check all that apply)

How did you hear about my services? (Please check all that apply) Google/Internet Search Yelp Facebook SAI Doulamatch.net Business card/brochure Referral from someone: Referral from someone:
Would you like to add Placenta Encapsulation Services onto your Belly Binding Services for a well-rounded postpartum recovery?

Would you like to add Placenta Encapsulation Services onto your Belly Binding Services for a well-rounded postpartum recovery? Yes, I want to reserve Placenta Encapsulation Services, too! I'm interested in learning more about Placenta Encapsulation, and would love more information. No, thank you! I'm not interested in Placenta Encapsulation.
Would you like to add Vaginal Steam Herbs onto your Belly Binding Services for a well-rounded postpartum recovery?

Would you like to add Vaginal Steam Herbs onto your Belly Binding Services for a well-rounded postpartum recovery? Yes, I want to add on postpartum Vaginal Steam Herbs! I have questions or would like to learn more about Vaginal Steaming. No, thank you! I'm not interested in Vaginal Steaming.
Belly Binding Service Descriptions:
Traditional Bandage Belly Binding ($75):

For this service, I will visit you at your birth location or home to do your first belly binding. During this time, a support person should be available to receive one-on-one instruction on how to do future bindings. The mother will be given a total of 2 bandages, to last approximately two weeks of binding, and verbal/demonstrated belly binding instructions. Written instructions will be given upon request. Traditional Bandage Binding is done with large elastic bandages that are wrapped back and forth around the woman's waistline and secured with clips. The bandages are lightweight and breathable enough to be worn under clothes and while sleeping at night, but also have enough elastic to achieve the desired fit. This binding is a gentle binding - it is not super tight like a girdle or corset. Extra tight bindings prevent your muscles from functioning properly during their healing time. The gentle Traditional Bandage Binding supports your muscles in both healing AND functioning properly. The benefits of belly binding include the following: helps your uterus return to its pre-pregnancy size, helps your abdominal muscles heal together correctly, helps your organs relocate themselves in your abdomen, decreases postpartum bleeding and reduces hemorrhaging, provides support and posture assistance during breastfeeding, prevents cold (imbalance) from entering the woman's body, gives the woman a sense of "togetherness," security and comfort.

Please check the box indicating you agree to this service:

Traditional Bandage Belly Binding ($75):

For this service, I will visit you at your birth location or home to do your first belly binding. During this time, a support person should be available to receive one-on-one instruction on how to do future bindings. The mother will be given a total of 2 bandages, to last approximately two weeks of binding, and verbal/demonstrated belly binding instructions. Written instructions will be given upon request. Traditional Bandage Binding is done with large elastic bandages that are wrapped back and forth around the woman's waistline and secured with clips. The bandages are lightweight and breathable enough to be worn under clothes and while sleeping at night, but also have enough elastic to achieve the desired fit. This binding is a gentle binding - it is not super tight like a girdle or corset. Extra tight bindings prevent your muscles from functioning properly during their healing time. The gentle Traditional Bandage Binding supports your muscles in both healing AND functioning properly. The benefits of belly binding include the following: helps your uterus return to its pre-pregnancy size, helps your abdominal muscles heal together correctly, helps your organs relocate themselves in your abdomen, decreases postpartum bleeding and reduces hemorrhaging, provides support and posture assistance during breastfeeding, prevents cold (imbalance) from entering the woman's body, gives the woman a sense of "togetherness," security and comfort.

Please check the box indicating you agree to this service: I Agree to Traditional Bandage Belly Binding ($75)
Any special requests?
Agreements
The CLIENT will call or text Marissa at 619-408-7008 as soon as possible after the baby is born, within the hours of 8:00am and 9:00pm, to schedule the belly binding. For example, if the baby is born after 9:00pm, please wait until 8:00am to contact Marissa.

The CLIENT will call or text Marissa at 619-408-7008 as soon as possible after the baby is born, within the hours of 8:00am and 9:00pm, to schedule the belly binding. For example, if the baby is born after 9:00pm, please wait until 8:00am to contact Marissa. I Agree.
CLIENT agrees that the bandage belly binding service is NOT intended for weight loss, slimming or waist training, and Marissa makes no claims of these results.

CLIENT agrees that the bandage belly binding service is NOT intended for weight loss, slimming or waist training, and Marissa makes no claims of these results. I Agree.
CLIENT agrees that the benefits of belly binding may vary from person to person depending on each person's own unique body and their commitment to daily belly binding and post-birth recovery & self-care.

CLIENT agrees that the benefits of belly binding may vary from person to person depending on each person's own unique body and their commitment to daily belly binding and post-birth recovery & self-care. I Agree.
PAYMENTS
The CLIENT agrees that the $75 fee for belly binding services is due to be paid in full at the time the services are booked.

PLEASE MAKE ALL PAYMENTS TO:
Marissa Lavroff
5760 Alta Vista Ave
San Diego, CA 92114

Or PayPal: MarissaLavroff@gmail.com (via the "friends/family" option ONLY)

Or Venmo: @Marissa-Lavroff

PAYMENTS
The CLIENT agrees that the $75 fee for belly binding services is due to be paid in full at the time the services are booked.

PLEASE MAKE ALL PAYMENTS TO:
Marissa Lavroff
5760 Alta Vista Ave
San Diego, CA 92114

Or PayPal: MarissaLavroff@gmail.com (via the "friends/family" option ONLY)

Or Venmo: @Marissa-Lavroff I Agree.
METHOD OF PAYMENT
Payment may be made in cash, money order, cashier’s check, check, credit card via PayPal or Venmo. A $25 fee will be charged for all returned checks.

METHOD OF PAYMENT
Payment may be made in cash, money order, cashier’s check, check, credit card via PayPal or Venmo. A $25 fee will be charged for all returned checks. I Agree.
CANCELLATION & REFUND
Once the services have been rendered, there will be no refund. If the CLIENT wishes to cancel services before the services are rendered, the CLIENT must notify Marissa to let her know. Any monies paid towards belly binding services before services have been rendered will be refunded.

CANCELLATION & REFUND
Once the services have been rendered, there will be no refund. If the CLIENT wishes to cancel services before the services are rendered, the CLIENT must notify Marissa to let her know. Any monies paid towards belly binding services before services have been rendered will be refunded. I Agree.
WAIVER OF LIABILITY
CLIENT understands that belly binding is not intended to prevent or treat any physical diseases, ailments or symptoms. The benefits of belly binding are not guaranteed.

WAIVER OF LIABILITY
CLIENT understands that belly binding is not intended to prevent or treat any physical diseases, ailments or symptoms. The benefits of belly binding are not guaranteed. I Agree.
Payment
Total fee for Traditional Bandage Belly Binding is $75.

Total fee for Traditional Bandage Belly Binding is $75. I Agree.
If we have verbally agreed on different amount based on your needs, please enter it here: $ Dollars . Cents
Do you have a Gift Certificate? If so, please type the gift code below:
Are you a surrogate? If so, which agency are you going through?

Are you a surrogate? If so, which agency are you going through? SAI Modern Family Surrogacy Conceptual Options It's Time Surrogacy West Coast Surrogacy Extraordinary Conceptions California Surrogacy Center Other Other
You may choose to pay the $75 fee now through PayPal or you may choose to make other payment arrangements. If you would like to make other payment arrangements, please submit this form and disregard the PayPal page when it opens.

You may choose to pay the $75 fee now through PayPal or you may choose to make other payment arrangements. If you would like to make other payment arrangements, please submit this form and disregard the PayPal page when it opens. Agree
Signature
I/We have read this agreement in its entirety and agree with what it states.

I/We have read this agreement in its entirety and agree with what it states. Agree
Draw your signature into the box below:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Belly Binding Agreement

Belly Binding Agreement

Belly Binding Service Descriptions:

Agreements

Payment

Signature