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 (how many per day and for how long)
-----Services & Packages-----
All services are performed in-home and include an umbilical cord keepsake
Basic Service $295*
Traditionally prepared capsules
Indicate add-ons below
Mother's Broth (FREE)
Placenta Tincture ($25)
Art Print in natural sepia ($10)
Art Print with food-based color ($15)
Placenta Healing Salve ($35)
Soothing Reiki, 30 mins ($20)
Moxibustion (warming therapy) ($10)
AromaTouch essential oil application (45 mins, @ 1 month post partum) - ($65)
Complete Care Package $425*
Basic Service + all the Add-ons!
with Natural Art
with Color Art
Please select BOTH Basic service box and Art choice. Please note in the comments box below if there are any add-ons you would prefer to skip.
A variable travel fee may apply to distances greater than 30 miles from my home.
-----Notes and Comments-----
Please leave a note with special considerations or other information pertinent to our ability to best serve you, including if you have a financial hardship.
I'm sorry i will not be able to perform encapsulation on a placenta that has tested positive for hep B/Hep c or hiv/aids - please contact me for alternative options
Please verify by checking below
Negative for infectious diseases
I would like to discuss alternative options
"Beyond The Placenta" - An occasional email sharing of healthy lifestyle resources and/or offerings from Crimson Roots
Yes! I want to connect "Beyond The Placenta"
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last updated on: 04/20/2022