Intake & History
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City, State, Zip
Estimated Due Date
How did you find Crimson Roots?
Please share a bit about your history and this pregnancy to help us serve you better
This is child #_ for me:
History of depression?
No personal history
(check all that apply)
Planned Birth Setting (if hospital, which one?)
Do you currently smoke cigarettes OR have you smoked at all during this pregnancy?
If yes, please elaborate.
-----Services & Packages-----
All services are performed in-home and include an umbilical cord keepsake
Basic Service $275*
Traditionally prepared capsules
Indicate add-ons below
A la Carte Add-ons
Mother's Broth (no charge)
Mother Essence Tincture ($25)
Art Print in natural sepia ($10)
Art Print with food-based color ($15)
Placenta Salve ($35)
Reiki, 30 mins ($20)
Moxa (Chinese heat application) ($10)
BEMER Therapy - 2 sessions ($50)
Complete Care Package $425*
Complete Care Package
Basic service plus all add-ons
Choose Your Art
with Natural Art
with Color Art
-----Notes and Comments-----
Please leave a note about special considerations or other information you feel is pertinent to our ability to best serve you
Prices are for local service (within 30 miles of my home). A variable travel fee may apply to further distances.
Please leave a note in the comments if you need a personalized payment arrangement. No one is turned away for the inability to pay.
I'm sorry i will not be able to encapsulate a placenta for anyone who is positive for hep B/Hep c or hiv/aids
Please verify by checking below
Negative for infectious diseases
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last updated on: 04/12/2021