Online Placenta Services Agreement - Marissa Lavroff

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

Estimated Due Date Estimated Due 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
OB/Midwife
Doula/Birth Attendant
Doula/Birth Attendant's Phone Number Doula/Birth Attendant's Phone Number - ### - ### ####
Have you encapsulated in the past?

Have you encapsulated in the past? Yes No Other Other
Any complications during this pregnancy?

Any complications during this pregnancy? No Yes, please explain: Yes, please explain:
Is this pregnancy a singleton or multiple gestation?

Is this pregnancy a singleton or multiple gestation? I am giving birth to one baby I am giving birth to 2 or more babies
Are you currently taking any medication that you will continue to take after you give birth?(This information is kept completely confidential and is requested to ensure the consumption of your placenta does not interfere with the dosage of any medications you are taking.)

Are you currently taking any medication that you will continue to take after you give birth?(This information is kept completely confidential and is requested to ensure the consumption of your placenta does not interfere with the dosage of any medications you are taking.) No Yes. Please list: Yes. Please list:
Do you have any allergies?

Do you have any allergies? No Yes. Please list: Yes. Please list:
Why have you chosen Placenta 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:
Base Placenta Service Descriptions
Placenta Capsules:
This method of preparing the placenta for encapsulation involves dehydrating the placenta until all of the moisture is removed. The placenta is then ground into a powder and encapsulated into vegetarian capsules for easy consumption.

Loose Placenta Powder:
Not a fan of swallowing pills? Loose placenta powder is great for adding to smoothies and food!

Whole Placenta Smoothies:
This is a great option for those who only want to have placenta smoothies. Your placenta is prepared raw into individually wrapped, frozen placenta cubes to add to smoothies. Anytime you need a raw placenta boost, blend your smoothie with a placenta cube! The number of frozen cubes depends on the size of your placenta. Your first smoothie is pre-made and delivered to you at your birthing location for immediate enjoyment.

Please select your Placenta Service:
Any special requests?
Placenta Add-On Services Descriptions
Placenta Smoothies (+$30):
This add-on service provides you with individually wrapped, frozen placenta cubes for approximately 1-2 weeks worth of smoothies (depending on if you have 1-2 smoothies per day). You can easily add your smoothie cubes to your favorite smoothie recipe, blend and enjoy!

Placenta Tincture, 4oz (+$30):
The placenta tincture is another way to reap the physical benefits from the placenta besides capsule form. Tinctures are great for energy, transition, stress, and hormone stabilization. They are excellent to use during menstrual cycles, menopause, and even the puberty of your daughter(s). Relatives on the maternal line of the birthing mom can also benefit from the tincture as it has an almost indefinite shelf life if stored properly. The tincture is made from a thumbnail-sized piece of raw placenta, which is steeped for 6 weeks in high-grade alcohol before it is used. It is stored in a 4oz dropper bottle.

Placenta Salve, 4oz (+$30):
The placenta salve has many uses. It is used to heal Cesarean section incision after the wound is closed and to reduce scarring, itching and discomfort. The salve can also be used as soon as 3 days postpartum for mom and baby to soothe hemorrhoids, perineal tears, diaper rash, eczema, sun burns, skin irritations, sore nipples, as an intensive moisturizer and for general healing & skin care. The placenta salve is a blend of organic coconut oil, almond oil, beeswax, calendula oil, plantain oil, comfrey oil, and lavender essential oil.

Natural Placenta Prints on Paper & Cord Keepsake (Complimentary):
Placenta prints and cord keepsakes are a great way to commemorate the beauty of the placenta and to honor the special role it played in your baby's growth and development. Placenta prints are made by rubbing acid-free art paper (11 x 14) onto the surface of the placenta to leave an impression of the placenta on the paper. The umbilical cord is preserved as a heart-shaped keepsake.

Placenta Services Add-On Selection:

Placenta Smoothies (+$30):
This add-on service provides you with individually wrapped, frozen placenta cubes for approximately 1-2 weeks worth of smoothies (depending on if you have 1-2 smoothies per day). You can easily add your smoothie cubes to your favorite smoothie recipe, blend and enjoy!

Placenta Tincture, 4oz (+$30):
The placenta tincture is another way to reap the physical benefits from the placenta besides capsule form. Tinctures are great for energy, transition, stress, and hormone stabilization. They are excellent to use during menstrual cycles, menopause, and even the puberty of your daughter(s). Relatives on the maternal line of the birthing mom can also benefit from the tincture as it has an almost indefinite shelf life if stored properly. The tincture is made from a thumbnail-sized piece of raw placenta, which is steeped for 6 weeks in high-grade alcohol before it is used. It is stored in a 4oz dropper bottle.

Placenta Salve, 4oz (+$30):
The placenta salve has many uses. It is used to heal Cesarean section incision after the wound is closed and to reduce scarring, itching and discomfort. The salve can also be used as soon as 3 days postpartum for mom and baby to soothe hemorrhoids, perineal tears, diaper rash, eczema, sun burns, skin irritations, sore nipples, as an intensive moisturizer and for general healing & skin care. The placenta salve is a blend of organic coconut oil, almond oil, beeswax, calendula oil, plantain oil, comfrey oil, and lavender essential oil.

Natural Placenta Prints on Paper & Cord Keepsake (Complimentary):
Placenta prints and cord keepsakes are a great way to commemorate the beauty of the placenta and to honor the special role it played in your baby's growth and development. Placenta prints are made by rubbing acid-free art paper (11 x 14) onto the surface of the placenta to leave an impression of the placenta on the paper. The umbilical cord is preserved as a heart-shaped keepsake.

Placenta Services Add-On Selection: Placenta Smoothie (+$30) 4oz Placenta Tincture (+$30) 4oz Placenta Salve (+$30) Natural Placenta Print on Paper (Complimentary) Cord Keepsake (Complimentary) If you would like multiples of any add-on services, please indicate which one(s) below:
Any special requests?
Watercolor Placenta Print (+$20):
This is a customized printing of your placenta in watercolor. These prints are great to frame and display in your baby's nursery or treasured as a keepsake from the pregnancy. Please note, watercolor prints will vary in their appearance - each print is a unique piece of art. The watercolor print is made on an 11 x 14 acid-free art paper and created in such a way that the paint does not come into direct contact with the placenta, keeping your placenta sanitary and safe for consumption/encapsulation. You may choose up to three (3) colors on the pallet below for your print. You can also see some examples of watercolor prints on our website at www.midwifecourtney.com/placenta-encapsulation.

Placenta Service Add-On Selection:

Watercolor Placenta Print (+$20):
This is a customized printing of your placenta in watercolor. These prints are great to frame and display in your baby's nursery or treasured as a keepsake from the pregnancy. Please note, watercolor prints will vary in their appearance - each print is a unique piece of art. The watercolor print is made on an 11 x 14 acid-free art paper and created in such a way that the paint does not come into direct contact with the placenta, keeping your placenta sanitary and safe for consumption/encapsulation. You may choose up to three (3) colors on the pallet below for your print. You can also see some examples of watercolor prints on our website at www.midwifecourtney.com/placenta-encapsulation.

Placenta Service Add-On Selection: Watercolor Placenta Print (+$20)
Color Option 1:
Color Selection 2 (optional):
Color Selection 3 (optional):
Any special requests for your watercolor print?

Please know that we will do our best to meet your special requests for watercolor prints. If you would like details added that are more extensive or require more time, there may be an additional charge, which is always discussed and confirmed with you before the art piece is done.
Placenta Pickup & Delivery
There are two options for transporting the placenta after the birth...

1. Placenta pickup at your birth location and delivery of your finished placenta products by Marissa are standard. There is no additional charge for this service.

2. To receive a $50 discount on placenta services, you may have someone you trust deliver your placenta to Marissa's home in Paradise Hills in San Diego within 4 hours of the birth. Marissa will still deliver your placenta products to you when she is finished preparing them. This option will bring the cost of placenta encapsulation down from $250 to $200 for a savings of $50.

Please select your pickup & delivery option:

There are two options for transporting the placenta after the birth...

1. Placenta pickup at your birth location and delivery of your finished placenta products by Marissa are standard. There is no additional charge for this service.

2. To receive a $50 discount on placenta services, you may have someone you trust deliver your placenta to Marissa's home in Paradise Hills in San Diego within 4 hours of the birth. Marissa will still deliver your placenta products to you when she is finished preparing them. This option will bring the cost of placenta encapsulation down from $250 to $200 for a savings of $50.

Please select your pickup & delivery option: I would like Marissa to pick up my placenta from my birth location after the birth. I will have someone deliver my placenta to Marissa's home in Paradise Hills in San Diego within 4 hours of the birth (-$50 SAVINGS).
Postpartum Wellness Add-Ons:
Traditional Bandage Belly Binding (+$75):
When I return your placenta capsules, I will 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 for the rest for the two week duration. The mother will be given a total of 2 bandages, bandage tape 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 medical tape. 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.

Postpartum Vaginal Steam Plan & Herbs (+$20):
Includes postpartum vaginal steam herbal blend (enough to steam once per day for two weeks), postpartum vaginal steam plan, vaginal steam setup guidance & instruction. Vaginal steaming after birth helps your perineum heal, reduces hemorrhoids, reduces the overall length of postpartum bleeding and decreases the risk of vaginal infection post-birth.

Postpartum Wellness Add-On Selections:

Traditional Bandage Belly Binding (+$75):
When I return your placenta capsules, I will 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 for the rest for the two week duration. The mother will be given a total of 2 bandages, bandage tape 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 medical tape. 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.

Postpartum Vaginal Steam Plan & Herbs (+$20):
Includes postpartum vaginal steam herbal blend (enough to steam once per day for two weeks), postpartum vaginal steam plan, vaginal steam setup guidance & instruction. Vaginal steaming after birth helps your perineum heal, reduces hemorrhoids, reduces the overall length of postpartum bleeding and decreases the risk of vaginal infection post-birth.

Postpartum Wellness Add-On Selections: Traditional Bandage Belly Binding (+$75) Postpartum Vaginal Steam Plan & Herbs (+$20)
Agreements
ENTIRE AGREEMENT
This agreement contains the entire understanding between SPECIALIST and the CLIENT. It supersedes all prior and simultaneous agreements between the parties. The only way to change or add to this agreement is to do so in writing with all the relevant parties signing provided document.

ENTIRE AGREEMENT
This agreement contains the entire understanding between SPECIALIST and the CLIENT. It supersedes all prior and simultaneous agreements between the parties. The only way to change or add to this agreement is to do so in writing with all the relevant parties signing provided document. I Agree.
RESERVATION
Upon your signature and payment, SPECIALIST will reserve the time and date agreed upon, and will not make other reservations around your estimated due date. For this reason, the encapsulation deposit of $50 is non-refundable, even if the service is canceled for any reason. The $50 deposit is to be paid at the time of signing contract.

RESERVATION
Upon your signature and payment, SPECIALIST will reserve the time and date agreed upon, and will not make other reservations around your estimated due date. For this reason, the encapsulation deposit of $50 is non-refundable, even if the service is canceled for any reason. The $50 deposit is to be paid at the time of signing contract. I Agree.
PAYMENTS
The CLIENT agrees that $50 deposit is required at the time of contract acceptance. This deposit applies to your total placenta services purchase. Remaining balance is due by CLIENT’s 37th week of pregnancy.

PAYMENTS
The CLIENT agrees that $50 deposit is required at the time of contract acceptance. This deposit applies to your total placenta services purchase. Remaining balance is due by CLIENT’s 37th week of pregnancy. I Agree.
METHOD OF PAYMENT
SPECIALIST will send you an online invoice, which outlines the total amount due. Payments may be made in the following ways...

• Pay directly on the online invoice via debit/credit or bank.

• Cash - in person.

• Checks - should be made out to Marissa Lavroff and mailed to 5760 Alta Vista Ave, San Diego CA 92114.

• PayPal - If you would like to avoid the 2.9% PayPal fee, you may send a payment through PayPal directly to my email (marissalavroff@gmail.com) via friends & family. If you need specific instructions, I am happy to provide them to you.

• Venmo - You can find me on Venmo @Marissa-Lavroff

Initial:

METHOD OF PAYMENT
SPECIALIST will send you an online invoice, which outlines the total amount due. Payments may be made in the following ways...

• Pay directly on the online invoice via debit/credit or bank.

• Cash - in person.

• Checks - should be made out to Marissa Lavroff and mailed to 5760 Alta Vista Ave, San Diego CA 92114.

• PayPal - If you would like to avoid the 2.9% PayPal fee, you may send a payment through PayPal directly to my email (marissalavroff@gmail.com) via friends & family. If you need specific instructions, I am happy to provide them to you.

• Venmo - You can find me on Venmo @Marissa-Lavroff

Initial: I Agree.
CANCELLATION & REFUND
No refund is given for services canceled after the 37th week of pregnancy. Services canceled prior to the 37th week of pregnancy will be refunded, less the non-refundable deposit. If the SPECIALIST is unable to provide placenta services due to illness or is otherwise incapacitated, SPECIALIST will send a back-up specialist. Contract will then be taken over by the back-up specialist. If SPECIALIST is unable to provide services and no back up specialist is available, the deposit and fee will be refunded in full. It is the CLIENT’s responsibility to get permission for release of the placenta from care provider. If CLIENT is unable to attain the placenta or it is contaminated before release and/or unable to be consumed for any reason beyond SPECIALIST’s control, there is no refund of deposit. Any further refunds will be at the discretion of the SPECIALIST and complimentary services may be offered in place of placenta services.

CANCELLATION & REFUND
No refund is given for services canceled after the 37th week of pregnancy. Services canceled prior to the 37th week of pregnancy will be refunded, less the non-refundable deposit. If the SPECIALIST is unable to provide placenta services due to illness or is otherwise incapacitated, SPECIALIST will send a back-up specialist. Contract will then be taken over by the back-up specialist. If SPECIALIST is unable to provide services and no back up specialist is available, the deposit and fee will be refunded in full. It is the CLIENT’s responsibility to get permission for release of the placenta from care provider. If CLIENT is unable to attain the placenta or it is contaminated before release and/or unable to be consumed for any reason beyond SPECIALIST’s control, there is no refund of deposit. Any further refunds will be at the discretion of the SPECIALIST and complimentary services may be offered in place of placenta services. I Agree.
BLOOD WORK
CLIENT will furnish SPECIALIST with a copy of prenatal blood screening that includes HIV and Hepatitis results. It is safe to consume your own placenta if you are positive for HIV and Hepatitis, however the encapsulation process will take place in your home and with your own tools, which you may need to purchase separately. It is not recommended to share your placenta products with anyone else when positive for an STD. SPECIALIST will provide a list of materials needed if you are positive for HIV or Hepatitis. SPECIALIST will return the copy of blood work to CLIENT before or upon delivery of the placenta products. SPECIALIST abides by all HIPPA privacy laws and does not share your personal information.

BLOOD WORK
CLIENT will furnish SPECIALIST with a copy of prenatal blood screening that includes HIV and Hepatitis results. It is safe to consume your own placenta if you are positive for HIV and Hepatitis, however the encapsulation process will take place in your home and with your own tools, which you may need to purchase separately. It is not recommended to share your placenta products with anyone else when positive for an STD. SPECIALIST will provide a list of materials needed if you are positive for HIV or Hepatitis. SPECIALIST will return the copy of blood work to CLIENT before or upon delivery of the placenta products. SPECIALIST abides by all HIPPA privacy laws and does not share your personal information. I Agree.
PLACENTA HANDLING POST-BIRTH
If SPECIALIST is not present at the birth as the doula, CLIENT agrees to contact SPECIALIST as soon as labor begins and then again after baby is born. CLIENT agrees to keep placenta in their sight at all times to ensure it does not go to a lab where it will be contaminated by chemicals or other harmful substances rendering it unsafe for consumption. If the hospital must test the placenta, a small piece can be taken off the maternal side and sent to the lab, while the intact placenta is stored properly within the CLIENT's sight. SPECIALIST will provide CLIENT with a labeled ziplock bag to store placenta (if home birth), otherwise hospital will provide a bag/container to store placenta. CLIENT agrees to then have the placenta placed immediately in a refrigerator (home birth) or cooler with ice (hospital or birth center). CLIENT is responsible for providing cooler. CLIENT understands that the same post birth care instructions apply to cesarean births.

PLACENTA HANDLING POST-BIRTH
If SPECIALIST is not present at the birth as the doula, CLIENT agrees to contact SPECIALIST as soon as labor begins and then again after baby is born. CLIENT agrees to keep placenta in their sight at all times to ensure it does not go to a lab where it will be contaminated by chemicals or other harmful substances rendering it unsafe for consumption. If the hospital must test the placenta, a small piece can be taken off the maternal side and sent to the lab, while the intact placenta is stored properly within the CLIENT's sight. SPECIALIST will provide CLIENT with a labeled ziplock bag to store placenta (if home birth), otherwise hospital will provide a bag/container to store placenta. CLIENT agrees to then have the placenta placed immediately in a refrigerator (home birth) or cooler with ice (hospital or birth center). CLIENT is responsible for providing cooler. CLIENT understands that the same post birth care instructions apply to cesarean births. I Agree.
WAIVER OF LIABILITY
CLIENT understands that choosing to encapsulate their placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that CLIENT is choosing to consume placenta for their own personal beliefs, whether it be spiritual or cultural. The benefits of placentophagy are not guaranteed.

WAIVER OF LIABILITY
CLIENT understands that choosing to encapsulate their placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that CLIENT is choosing to consume placenta for their own personal beliefs, whether it be spiritual or cultural. The benefits of placentophagy are not guaranteed. I Agree.
CALIFORNIA LEGALITIES
There are NO State mandated regulations in CA barring placental release or consumption. The place of birth may have policies and may require a release form. CLIENT is responsible for determining the policy of their birth place during pregnancy and informing the care giver that CLIENT plans to consume placenta.

CALIFORNIA LEGALITIES
There are NO State mandated regulations in CA barring placental release or consumption. The place of birth may have policies and may require a release form. CLIENT is responsible for determining the policy of their birth place during pregnancy and informing the care giver that CLIENT plans to consume placenta. I Agree.
RISKS OF PLACENTA CONSUMPTION
CLIENT understands the risks of placenta consumption are the same as dining out in a restaurant where the food is prepared for you. Other risks may include: placenta being switched with another placenta that is not the CLIENT’s at the hospital; placenta contamination with chemicals at the hospital pathology laboratory; and contamination during transport (either by hospital or CLIENT failing to store properly).

RISKS OF PLACENTA CONSUMPTION
CLIENT understands the risks of placenta consumption are the same as dining out in a restaurant where the food is prepared for you. Other risks may include: placenta being switched with another placenta that is not the CLIENT’s at the hospital; placenta contamination with chemicals at the hospital pathology laboratory; and contamination during transport (either by hospital or CLIENT failing to store properly). I Agree.
CLIENT acknowledges that SPECIALIST has provided concrete information about the benefits and risks of placenta encapsulation and have read all included documents. CLIENT understands that the placenta has been handled and encapsulated according to OSHA and CA Food Safety and Handling standards, as has been cleaned, steamed (TCMi method), dehydrated and put into pill form in a sanitary and sterile work space. Upon receiving placenta capsules or other placenta products, CLIENT waives any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules.

CLIENT acknowledges that SPECIALIST has provided concrete information about the benefits and risks of placenta encapsulation and have read all included documents. CLIENT understands that the placenta has been handled and encapsulated according to OSHA and CA Food Safety and Handling standards, as has been cleaned, steamed (TCMi method), dehydrated and put into pill form in a sanitary and sterile work space. Upon receiving placenta capsules or other placenta products, CLIENT waives any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules. I Agree.
CLIENT does not hold SPECIALIST responsible or liable for any transport mishap that is beyond the SPECIALIST's control (ex: car accident). CLIENT understands that the placenta will be prepared in the SPECIALIST’s home and returned to the CLIENT as soon as it is finished. Preparation may take up to 4 days to complete.

CLIENT does not hold SPECIALIST responsible or liable for any transport mishap that is beyond the SPECIALIST's control (ex: car accident). CLIENT understands that the placenta will be prepared in the SPECIALIST’s home and returned to the CLIENT as soon as it is finished. Preparation may take up to 4 days to complete. I Agree.
CLIENT understands that if their blood work shows a positive result for HIV or Hepatitis, placenta preparation will take place in their home with their tools. If placenta is prepared in the SPECIALIST’s home, CLIENT places full trust and acknowledgement that it is being handled in a sanitary and safe environment. CLIENT has provided SPECIALIST with blood work stating that CLIENT has been tested for HIV and Hepatitis and the results were negative. CLIENT understands that blood work documentation is collected for each client and that the information is kept confidential in accordance with HIPPA laws.

CLIENT understands that if their blood work shows a positive result for HIV or Hepatitis, placenta preparation will take place in their home with their tools. If placenta is prepared in the SPECIALIST’s home, CLIENT places full trust and acknowledgement that it is being handled in a sanitary and safe environment. CLIENT has provided SPECIALIST with blood work stating that CLIENT has been tested for HIV and Hepatitis and the results were negative. CLIENT understands that blood work documentation is collected for each client and that the information is kept confidential in accordance with HIPPA laws. I Agree.
CLIENT understands that upon receiving placenta pills and products, SPECIALIST is not liable, including but not limited to any other persons, ingesting CLIENT’s placenta.

CLIENT understands that upon receiving placenta pills and products, SPECIALIST is not liable, including but not limited to any other persons, ingesting CLIENT’s placenta. I Agree.
Payment
The total Placenta Service Package fee includes the Base Placenta Service fee plus the fees for any Add-On Services.

The total Placenta Service Package fee includes the Base Placenta Service fee plus the fees for any Add-On Services. I Agree.
Is Courtney Scott your midwife or doula monitrice? If so, please type 'midwife' in the box below to waive the $50 deposit:
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:
You may choose to pay the $50 deposit 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 $50 deposit 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
After you pay the deposit, if you choose to pay the remaining balance through PayPal, a 2.9% fee will be applied.

After you pay the deposit, if you choose to pay the remaining balance through PayPal, a 2.9% fee will be applied. 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
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Online Placenta Services Agreement - Marissa Lavroff

Online Placenta Services Agreement - Marissa Lavroff

Base Placenta Service Descriptions

Placenta Add-On Services Descriptions

Placenta Pickup & Delivery

Postpartum Wellness Add-Ons:

Agreements

Payment

Signature