{"id":469,"date":"2017-09-24T02:28:48","date_gmt":"2017-09-24T02:28:48","guid":{"rendered":"https:\/\/purelyplacentas.com\/?post_type=portfolio&#038;p=469"},"modified":"2020-05-06T01:41:32","modified_gmt":"2020-05-06T01:41:32","slug":"client-intake-form","status":"publish","type":"portfolio","link":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/","title":{"rendered":"Client Intake Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Client Booking Form<\/h3>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/index.php\/wp-json\/wp\/v2\/portfolio\/469#gf_3' data-formid='3' >\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_13\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_13'>\n                            \n                            <span id='input_3_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_3_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_3_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_12\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\"><label class='gfield_label gform-field-label' for='input_3_12' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_3_12' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_11\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\"><label class='gfield_label gform-field-label' for='input_3_11' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_3_11' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_9\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_3_9_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_9_1' id='input_3_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_9_2_container' >\n                                        <input type='text' name='input_9.2' id='input_3_9_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_9_2' id='input_3_9_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_3_9_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_9_3' id='input_3_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_9_4_container' >\n                                        <input type='text' name='input_9.4' id='input_3_9_4' value=''      aria-required='true'    \/>\n                                        <label for='input_3_9_4' id='input_3_9_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_3_9_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_9_5' id='input_3_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_3_9_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_14\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\"><label class='gfield_label gform-field-label' for='input_3_14' >Estimated Due Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_14' id='input_3_14' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_14_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_14_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_14' class='gform_hidden' value='https:\/\/purelyplacentas.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_15\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Partner or Contact Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_15'>\n                            \n                            <span id='input_3_15_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.3' id='input_3_15_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_15_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_15_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.6' id='input_3_15_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_15_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_3_15'>Attending the birth<\/div><\/li><li id=\"field_3_16\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\"><label class='gfield_label gform-field-label' for='input_3_16' >Partner\/Contact&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_3_16' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_19\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\"><label class='gfield_label gform-field-label' for='input_3_19' >Location of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_19'>ie, home, specific hospital, or birth center<\/div><\/li><li id=\"field_3_20\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address of Birth Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_20' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_20_1_container' >\n                                        <input type='text' name='input_20.1' id='input_3_20_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_20_1' id='input_3_20_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_20_2_container' >\n                                        <input type='text' name='input_20.2' id='input_3_20_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_20_2' id='input_3_20_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_20_3_container' >\n                                    <input type='text' name='input_20.3' id='input_3_20_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_20_3' id='input_3_20_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_20_4_container' >\n                                        <input type='text' name='input_20.4' id='input_3_20_4' value=''      aria-required='true'    \/>\n                                        <label for='input_3_20_4' id='input_3_20_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_20_5_container' >\n                                    <input type='text' name='input_20.5' id='input_3_20_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_20_5' id='input_3_20_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_20.6' id='input_3_20_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_22\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\"><label class='gfield_label gform-field-label' for='input_3_22' >Name of Midwife or OB\/GYN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_3_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\"><label class='gfield_label gform-field-label'  >Place of Preparation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_18'>\n\t\t\t<li class='gchoice gchoice_3_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='In my home'  id='choice_3_18_0'    \/>\n\t\t\t\t<label for='choice_3_18_0' id='label_3_18_0' class='gform-field-label gform-field-label--type-inline'>In my home<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='In specialist&#039;s workspace'  id='choice_3_18_1'    \/>\n\t\t\t\t<label for='choice_3_18_1' id='label_3_18_1' class='gform-field-label gform-field-label--type-inline'>In specialist's workspace<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_18'>See FAQ page from pros and cons of each location.<\/div><\/li><li id=\"field_3_36\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Have you had any of the following during this pregnancy? Please check all that apply even if you have received treatment. If you have a history of the following, check the &quot;Other&quot; box and add to the notes at the bottom of the form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_36'><li class='gchoice gchoice_3_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='None'  id='choice_3_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_1' id='label_3_36_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Group B Strep (GBS+)'  id='choice_3_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_2' id='label_3_36_2' class='gform-field-label gform-field-label--type-inline'>Group B Strep (GBS+)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Hepatitis A\/B\/C'  id='choice_3_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_3' id='label_3_36_3' class='gform-field-label gform-field-label--type-inline'>Hepatitis A\/B\/C<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='HSV'  id='choice_3_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_4' id='label_3_36_4' class='gform-field-label gform-field-label--type-inline'>HSV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='Other STI\/STDs (HIV, Gonorrhea, Chlamydia, etc)'  id='choice_3_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_5' id='label_3_36_5' class='gform-field-label gform-field-label--type-inline'>Other STI\/STDs (HIV, Gonorrhea, Chlamydia, etc)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.6' type='checkbox'  value='MRSA'  id='choice_3_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_6' id='label_3_36_6' class='gform-field-label gform-field-label--type-inline'>MRSA<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.7' type='checkbox'  value='HPV'  id='choice_3_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_7' id='label_3_36_7' class='gform-field-label gform-field-label--type-inline'>HPV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_36_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.8' type='checkbox'  value='Other Infections\/Diseases'  id='choice_3_36_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_36_8' id='label_3_36_8' class='gform-field-label gform-field-label--type-inline'>Other Infections\/Diseases<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_21\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\"><label class='gfield_label gform-field-label' for='input_3_21' >List Any Allergies<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_3_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_76\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_76\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Choose Your Placenta Package<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_76'><li class='gchoice gchoice_3_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='Basic Encapsulation Package ($325) includes placenta encapsulation, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions.'  id='choice_3_76_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_76_1' id='label_3_76_1' class='gform-field-label gform-field-label--type-inline'>Basic Encapsulation Package ($325) includes placenta encapsulation, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='Premium Encapsulation Package ($350) includes placenta encapsulation and a placenta tincture, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions.'  id='choice_3_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_76_2' id='label_3_76_2' class='gform-field-label gform-field-label--type-inline'>Premium Encapsulation Package ($350) includes placenta encapsulation and a placenta tincture, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_76_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.3' type='checkbox'  value='Gold Standard Encapsulation Package ($375) includes placenta encapsulation, plus your choice of any\/all add-ons, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions.'  id='choice_3_76_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_76_3' id='label_3_76_3' class='gform-field-label gform-field-label--type-inline'>Gold Standard Encapsulation Package ($375) includes placenta encapsulation, plus your choice of any\/all add-ons, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_46\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_46\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Travel Fee<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_46'><li class='gchoice gchoice_3_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Yes, I need to pay for a travel fee.'  id='choice_3_46_1'   aria-describedby=\"gfield_description_3_46\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_46_1' id='label_3_46_1' class='gform-field-label gform-field-label--type-inline'>Yes, I need to pay for a travel fee.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='No, I&#039;m inside the service area.'  id='choice_3_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_46_2' id='label_3_46_2' class='gform-field-label gform-field-label--type-inline'>No, I'm inside the service area.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_46'>If you are outside Jefferson County or beyond Baptist Floyd or Clark Memorial, there is a $40 fee for the extra travel required.<\/div><\/li><li id=\"field_3_25\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\"><label class='gfield_label gform-field-label'  >Complimentary Cord Keepsake<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_25'>\n\t\t\t<li class='gchoice gchoice_3_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes, please include a cord keepsake.'  id='choice_3_25_0'    \/>\n\t\t\t\t<label for='choice_3_25_0' id='label_3_25_0' class='gform-field-label gform-field-label--type-inline'>Yes, please include a cord keepsake.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No, I&#039;m not interested a cord keepsake.'  id='choice_3_25_1'    \/>\n\t\t\t\t<label for='choice_3_25_1' id='label_3_25_1' class='gform-field-label gform-field-label--type-inline'>No, I'm not interested a cord keepsake.<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_25'>This is included in all packages, please specify if you want this service.<\/div><\/li><li id=\"field_3_43\"  class=\"gfield gfield--type-product gfield--input-type-select gfield_price gfield_price_3_43 gfield_product_3_43 field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_43\"><label class='gfield_label gform-field-label' for='input_3_43' >Payment<\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_3_43' class='medium gfield_select'  aria-describedby=\"gfield_description_3_43\"   aria-invalid=\"false\" ><option value='$50' >Booking Deposit<\/option><option value='$350' >Basic Package<\/option><option value='$375' >Premium Package<\/option><option value='$400' >Gold Star Package<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_3_43'>Choose a product.<\/div><\/li><li id=\"field_3_37\"  class=\"gfield gfield--type-option gfield--type-choice gfield--input-type-checkbox gfield_price gfield_price_3_43 gfield_option_3_43 gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Payment Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_37'><li class='gchoice gchoice_3_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Booking Deposit|50'  id='choice_3_37_1'   aria-describedby=\"gfield_description_3_37\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_1' id='label_3_37_1' class='gform-field-label gform-field-label--type-inline'>Booking Deposit<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Basic Package|325'  id='choice_3_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_2' id='label_3_37_2' class='gform-field-label gform-field-label--type-inline'>Basic Package<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Premium Package|350'  id='choice_3_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_3' id='label_3_37_3' class='gform-field-label gform-field-label--type-inline'>Premium Package<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Gold StarPackage|375'  id='choice_3_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_4' id='label_3_37_4' class='gform-field-label gform-field-label--type-inline'>Gold Star Package<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.5' type='checkbox'  value='Digital Photo Art|15'  id='choice_3_37_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_5' id='label_3_37_5' class='gform-field-label gform-field-label--type-inline'>Digital Photo Art (add on)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.6' type='checkbox'  value='Beyond Jefferson County Hospitals and Clark Memorial\/Baptist Floyd Hospitals|40'  id='choice_3_37_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_6' id='label_3_37_6' class='gform-field-label gform-field-label--type-inline'>Travel Fee<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.7' type='checkbox'  value='Twin Fee|50'  id='choice_3_37_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_7' id='label_3_37_7' class='gform-field-label gform-field-label--type-inline'>Twin Fee<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_37_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.8' type='checkbox'  value='Will arrange drop off and pick up.|-35'  id='choice_3_37_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_37_8' id='label_3_37_8' class='gform-field-label gform-field-label--type-inline'>Self-Transport<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_37'>Choose to pay a booking deposit or pay for your package in full. If you choose to only pay the deposit, the balance is due before services are rendered. <\/div><\/li><li id=\"field_3_26\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >How Did You Hear About Purely Placenta Arts, LLC?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_26'><li class='gchoice gchoice_3_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Google'  id='choice_3_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>Google<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Facebook'  id='choice_3_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_2' id='label_3_26_2' class='gform-field-label gform-field-label--type-inline'>Facebook<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Baby Fair\/Event'  id='choice_3_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_3' id='label_3_26_3' class='gform-field-label gform-field-label--type-inline'>Baby Fair\/Event<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Referral (personal, healthcare provider, doula, etc.)'  id='choice_3_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_4' id='label_3_26_4' class='gform-field-label gform-field-label--type-inline'>Referral (personal, healthcare provider, doula, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_27\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\"><label class='gfield_label gform-field-label' for='input_3_27' >Please let me know if you were referred by someone so that I may thank them!<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_3_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_28\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\"><label class='gfield_label gform-field-label' for='input_3_28' >Any other notes<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_47' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-47' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_57\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_57\"><h2 class=\"gsection_title\">Purely Placenta Arts, LLC<\/h2><div class='gsection_description' id='gfield_description_3_57'>Please read the following general policies carefully and fill out and check the consent boxes where necessary. All service preferences and health information listed on your intake form have been noted. Please sign and date at the end prior to returning your completed form. Purely Placenta Arts, LLC respects your right to privacy and assure you that all information will be held in the strictest confidence.<\/div><\/li><li id=\"field_3_58\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_58\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_58'>\n                            \n                            <span id='input_3_58_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.3' id='input_3_58_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_58_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_58_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.6' id='input_3_58_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_58_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_61\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_61\"><label class='gfield_label gform-field-label' for='input_3_61' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_61' id='input_3_61' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_62\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_62\"><h2 class=\"gsection_title\">Placenta Encapsulation Description<\/h2><div class='gsection_description' id='gfield_description_3_62'>Placenta encapsulation is the process of preparing the mother\u2019s placenta after the birth of the baby by steaming, dehydrating, powdering and placing it into capsules for the mother to ingest. OSHA blood-borne pathogen universal safety protocols and proper food handling guidelines are followed closely. The purpose of ingestion of the placenta is to reintroduce beneficial hormones, proteins, and other nutrients to her body following labor and birth to help restore balance and provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period. <\/div><\/li><li id=\"field_3_63\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_63\"><h2 class=\"gsection_title\">Clarification of Services and Disclaimer<\/h2><div class='gsection_description' id='gfield_description_3_63'>I, Sarah Toma (APPAC), am not a licensed medical professional and I am not able to diagnose, treat, or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are guaranteed. Benefits will vary from person to person. Many of the reported benefits of placenta consumption are supported by ongoing research; however these benefits have not been evaluated or approved by the FDA or any other regulatory organizations. It is your responsibility to determine whether using placenta preparations may be of benefit to you. <\/div><\/li><li id=\"field_3_64\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_64\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_64.1' id='input_3_64_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_64_1' >I acknowledge and agree to the above clarification and disclaimer statement.<\/label><input type='hidden' name='input_64.2' value='I acknowledge and agree to the above clarification and disclaimer statement.' class='gform_hidden' \/><input type='hidden' name='input_64.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_3_65\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_65\"><h2 class=\"gsection_title\">Storage Guidelines<\/h2><div class='gsection_description' id='gfield_description_3_65'>Whether birthing at home or in a hospital, please ensure that your placenta is kept fresh. It can remain at room temperature for no longer than 2 hours following the birth. After that, (or sooner if possible) it should be refrigerated or otherwise kept cool. If you are practicing some form of delayed cord cutting, ice packs may be wrapped up with the placenta to prevent spoilage for up to 4 hours postpartum. Placenta encapsulation cannot be done after a traditional lotus birth. It is highly recommended that you place a cooler (a styrofoam cooler is acceptable) along with 2 freezer bags in your trunk by 36 weeks. Hospitals generally provide plastic containers, but for a home birth, double bagging the placenta in freezer bags is preferred.<\/div><\/li><li id=\"field_3_66\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_66\"><h2 class=\"gsection_title\">Client Storage Responsibility<\/h2><div class='gsection_description' id='gfield_description_3_66'>It is your responsibility to discuss release of your placenta from the hospital or where you give birth and to ensure proper storage of your placenta in a refrigerator (below 40 degrees F) or cooler packed with ice until it can be picked up for preparation and encapsulation. *If you are delivering at Norton Suburban, they have a 24hr hold policy and will keep your placenta in a refrigerator at Labor and Delivery. I recommend that you confirm the refrigerator is kept below 40 degrees F for food safety guidelines.<\/div><\/li><li id=\"field_3_67\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_67\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_67.1' id='input_3_67_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_67_1' >I acknowledge and agree to the above client responsibility statement.<\/label><input type='hidden' name='input_67.2' value='I acknowledge and agree to the above client responsibility statement.' class='gform_hidden' \/><input type='hidden' name='input_67.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_3_68\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_68\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Suitability for Consumption<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_68.1' id='input_3_68_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_68_1' >I understand that Sarah Toma does not determine whether or not my placenta is suitable for consumption; it is your responsibility to discuss this with your care provider.<\/label><input type='hidden' name='input_68.2' value='I understand that Sarah Toma does not determine whether or not my placenta is suitable for consumption; it is your responsibility to discuss this with your care provider.' class='gform_hidden' \/><input type='hidden' name='input_68.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_3_69\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_69\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >BBP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_69.1' id='input_3_69_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_69_1' >I understand that I must inform Sarah Toma, APPAC, of any known blood-borne illness or other health issues (such as HIV, hepatitis, etc.).  In the interest of safety, I understand that I must request in-home encapsulation. I understand that Sarah Toma will not encapsulate in her workspace in this scenario.<\/label><input type='hidden' name='input_69.2' value='I understand that I must inform Sarah Toma, APPAC, of any known blood-borne illness or other health issues (such as HIV, hepatitis, etc.).  In the interest of safety, I understand that I must request in-home encapsulation. I understand that Sarah Toma will not encapsulate in her workspace in this scenario.' class='gform_hidden' \/><input type='hidden' name='input_69.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_3_70\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_70\"><h2 class=\"gsection_title\">Unexpected Circumstances<\/h2><div class='gsection_description' id='gfield_description_3_70'>It is important to note that there may be circumstances under which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Other conditions, such as signs of infection in the mother or baby during labor or within 12 hours, may mean that consuming your placenta will not be beneficial to you. If in doubt, consult your care provider before proceeding. Please be sure to contact me if you or your baby develops an infection within 12 hours of giving birth.  I will discontinue the encapsulation process and you will get a refund of all but the non-refundable $50 deposit. We can also plan for different possible keepsakes, or placenta prints if your doctors will release it. \n\nIt should not be a problem to claim and keep your placenta after Caesarean surgery. To be prepared, it is recommended that your desire to take your placenta be written on a birth plan, and communicated by yourself, spouse, or doula in the event of an unplanned Caesarean surgery. I always recommend restating that you are keeping your placenta after you deliver.\n<\/div><\/li><li id=\"field_3_71\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_71\"><h2 class=\"gsection_title\">Fees<\/h2><div class='gsection_description' id='gfield_description_3_71'>Fees include the pick up of the placenta, preparation and encapsulation of the placenta, and other chosen services, written instructions for storage and handling, guidelines for taking your capsules, and delivery of your capsules. An umbilical cord keepsake is also provided whenever possible. A $50 non-refundable retainer fee is due upon signing this contract. Balance payment can be made by check (to Sarah Toma) or via PayPal for an extra 3% fee. The balance is payable before or upon pick-up of your placenta. If cost is an issue, please ask about payment plan options.  <\/div><\/li><li id=\"field_3_72\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_72\"><h2 class=\"gsection_title\">Refunds<\/h2><div class='gsection_description' id='gfield_description_3_72'>If you choose to terminate this contract after releasing your placenta to me, but before any preparation has begun, I will return your placenta to you for disposal. Your $50 retainer fee is not refunded.\n\nThere will be no refund and payment will be due in full once preparation has begun, even if you choose not to take the delivery of the finished capsules.\n\nIf something happens beyond your control that makes the placenta unsuitable for preparing (infection, sent to pathology, etc) then a refund will be given.\n<\/div><\/li><li id=\"field_3_73\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_73\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Final Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_73.1' id='input_3_73_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_73_1' >I have read and agree to the terms of this client agreement.<\/label><input type='hidden' name='input_73.2' value='I have read and agree to the terms of this client agreement.' class='gform_hidden' \/><input type='hidden' name='input_73.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_3_74\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_74\"><label class='gfield_label gform-field-label' for='input_3_74' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_74' id='input_3_74' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_74_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_74_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_74' class='gform_hidden' value='https:\/\/purelyplacentas.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_75\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_75\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >E-Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_75'>\n                            \n                            <span id='input_3_75_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.3' id='input_3_75_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_75_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_75_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.6' id='input_3_75_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_75_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_3_75_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.8' id='input_3_75_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_75_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><div class='gfield_description' id='gfield_description_3_75'>By typing my full name and date in the form above, I am using this as my electronic signature and agree to the terms of this agreement with Sarah Toma of Purely Placenta Arts, LLC. <\/div><\/li><li id=\"field_3_77\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_77\"><label class='gfield_label gform-field-label' for='input_3_77' >Email<\/label><div class='ginput_container'><input name='input_77' id='input_3_77' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_3_77'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_3\"]){return false;}  window[\"gf_submitting_3\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_3\"]){return false;} window[\"gf_submitting_3\"]=true;  jQuery(\"#gform_3\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_3' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_3\"]){return false;}  window[\"gf_submitting_3\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_3\"]){return false;} window[\"gf_submitting_3\"]=true;  jQuery(\"#gform_3\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=1&amp;description=&amp;tabindex=0&amp;theme=data-form-theme=&#039;legacy&#039;' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='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' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_3' id='gform_ajax_frame_3' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/purelyplacentas.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_3').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/purelyplacentas.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_3').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}, 50);}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [3, current_page]);gform.utils.trigger({ event: 'gform\/postRender', native: false, data: { formId: 3, currentPage: current_page } });} );} );\n<\/script>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"featured_media":0,"comment_status":"closed","ping_status":"closed","template":"","tags":[],"portfolio_entries":[],"class_list":["post-469","portfolio","type-portfolio","status-publish","hentry"],"wppr_data":{"cwp_meta_box_check":"No"},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Client Intake Form -<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Client Intake Form -\" \/>\n<meta property=\"og:url\" content=\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/purelyplacentas\/\" \/>\n<meta property=\"article:modified_time\" content=\"2020-05-06T01:41:32+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/\",\"url\":\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/\",\"name\":\"Client Intake Form -\",\"isPartOf\":{\"@id\":\"https:\/\/purelyplacentas.com\/#website\"},\"datePublished\":\"2017-09-24T02:28:48+00:00\",\"dateModified\":\"2020-05-06T01:41:32+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/purelyplacentas.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Client Intake Form\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/purelyplacentas.com\/#website\",\"url\":\"https:\/\/purelyplacentas.com\/\",\"name\":\"\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/purelyplacentas.com\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Client Intake Form -","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/","og_locale":"en_US","og_type":"article","og_title":"Client Intake Form -","og_url":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/","article_publisher":"https:\/\/www.facebook.com\/purelyplacentas\/","article_modified_time":"2020-05-06T01:41:32+00:00","twitter_card":"summary_large_image","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/","url":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/","name":"Client Intake Form -","isPartOf":{"@id":"https:\/\/purelyplacentas.com\/#website"},"datePublished":"2017-09-24T02:28:48+00:00","dateModified":"2020-05-06T01:41:32+00:00","breadcrumb":{"@id":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/purelyplacentas.com\/index.php\/portfolio-item\/client-intake-form\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/purelyplacentas.com\/"},{"@type":"ListItem","position":2,"name":"Client Intake Form"}]},{"@type":"WebSite","@id":"https:\/\/purelyplacentas.com\/#website","url":"https:\/\/purelyplacentas.com\/","name":"","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/purelyplacentas.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/portfolio\/469","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/portfolio"}],"about":[{"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/types\/portfolio"}],"replies":[{"embeddable":true,"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/comments?post=469"}],"version-history":[{"count":1,"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/portfolio\/469\/revisions"}],"predecessor-version":[{"id":621,"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/portfolio\/469\/revisions\/621"}],"wp:attachment":[{"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/media?parent=469"}],"wp:term":[{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/tags?post=469"},{"taxonomy":"portfolio_entries","embeddable":true,"href":"https:\/\/purelyplacentas.com\/index.php\/wp-json\/wp\/v2\/portfolio_entries?post=469"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}