Placenta Client Intake Form

Thank you for choosing Barefooted Beginnings for your placenta encapsulation! Please fill out the form below before we can move forward. Once filled out, I’ll be reaching out with approval and a link for payment.

I appreciate your support and my prayer is that I get to support you in the best way possible during your postpartum journey.

Blessings,

Melina Laverde

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(917) 680-3201

barefootedbeginnings@gmail.com

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Greater Houston Area
(Serving Houston and surrounding areas)

Intake Form

Fill out the form below, and I’ll get back to you as soon as possible.

Name

Last name

Phone

Birth Location

Home

Hospital

Birthing Center

Pickup Address

Drop off Address

Allergies

How did you find my services?

Any medications or supplements currently taking?

Do you smoke, consume alcohol or any other substance?

Any history of anxiety, depression, panic attacks, or chronic insomnia?

Any pregnancy related medical conditions?

Do you have any of the following? Note: All information will be confidential.

HIV/ AIDS- Please note, you will not be able to encapsulate

Hepatitis B- Please note, you will not be able to encapsulate

Hepatitis C- Please note, you will not be able to encapsulate

Any other STD/ STI?

None of the above

If yes, to any other, please specify. Note: All information will be confidential.

I, the potential client, understand that all information asked for is confidential. I, the potential client, understand that this form does not guarantee booking and will need to be approved before moving forward with a payment and confirmation of service

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Barefooted Beginnings

Placenta Client Intake Form

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Intake Form

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