BTV ~ Registration for Placenta Services

Birth Takes a Village works in partnership with New Spirit Arrivals ~ Birth + Postpartum Services, to provide numerous placenta related services. Please email Rylie@newspiritarrivals.ca if you have questions about these services.

Once you have completed both pages of this form and submitted it, you can expect to receive a confirmation email within 24 hours. At that time you will be provided with instructions on how the placenta should be handled and stored, and how and when to be in contact during your birthing time.

All information you share here is kept confidential. Please answer all questions honestly.

Birthing Person's Name * First Last
Birthing Person's Email *
Birthing Person's Phone * - ### - ### ####
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Partner (Friend or Family Member) First Last
This should be the person who will assist you with contacting me to arrange pickup or delivery.
Birth Partner's Email
Birth Partner's Phone - ### - ### ####
Birthing Person's Estimated Due Date * / MM / DD YYYY
Planned Place of Birth *
Home Hospital
Which hospital/backup hospital?
Any health concerns during your pregnancy?
Do you have any allergies? *
Have you ever been diagnosed with any of the following blood borne diseases? *
Hepatitis B or C HIV Human T-lymphotropic virus (HTLV-1 or -2) Syphillis None Other
Do you have other children?
If so, what was your postpartum recovery like? Any issues with breastfeeding?