Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Address *Birth Partner's Name and NumberMidwife/Doula's Name and NumberBaby Due Date *Birth NumberPlanned Place of Birth and Address *Have you spoken to your midwife about your choice to encapsulate? *YesNoHave you read our information guide for expectant mothers? *YesNoClick HERE to view the guide for expectant mothersDo you have any allergies, or are you taking any medication? If yes please give details below.Have you ever tested positive for the following? This information is required for our safeguarding *AIDSHIVHep BHep CNoneHave you been diagnosed and/treated for Streb B?YesNoHave you smoked regularly during this pregnancy?YesNoHow did you hear about The Placenta Connection?Services you would like to choose - Please see services and prices page for more informationSimple Capsules £220Steamed Capsules £22050/50 Capsules £275Placenta Oil 50ml £35Placenta Tincture £80Facial Oil 50ml £65Whipped Body Cream £55Balm for Mother and Baby £45Cord Keepsake (complimentary)Homeopathic Remedy £60The Natural Connection £260The Essential Connection £245The Bonding Connection £280The Ultimate Connection £440The Combined Connection 4 Services -15%How would you like to pay? *Bank transferPaypal friends and familyCredit card (1% handling fee)Terms of service *I agree to Terms & ConditionsClick HERE to view our terms & conditions Submit Some Hospitals/Areas require a collection which will be confirmed at the time of booking