EmailMe Form - Go2clinic Phlebotomist Booking Form

Name of the Expecting Mother

First Middle Last

Date of birth

MM / DD / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Mobile Phone

Home Phone

Partner's Contact details

Please provide the contact details of your partner or carer.

Name

First Middle Last

Email

Phone

Any instructions for contacting you?

Your Birth Plan details

Are you having a:

Hospital Birth

Home Birth

Name of Hospital if applicable

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Expected Mode of Delivery

Normal Vaginal Delivery (NVD)

Caesarean Section (C-Section)

Water Birth (NVD)

NVD by Induction

Estimated Due Date or
Date of your C-Section
or Induction:

MM / DD / YYYY

Time of C-Section or Induction (if known)

Are you expecting:

Singleton

Twins

Triplets

Is this your:

First Baby

Second Baby

Third Baby

Fourth Baby

Do you have a history of quick labour in the past or any other conditions that you think we should know about?

Name of the Cell Bank you have registered with?

Do we have your consent to procure your forthcoming baby's cord blood sample?

Yes

No

Do we have your consent to procure your forthcoming baby's cord tissue sample?

Yes

No

Do we have your consent to procure a blood sample from yourself?

Yes

No

Do you want us to collect a sample of the cord tissue as well?

Yes

No

Are you having placenta encapsulation service booked ?

Yes

No

Please select one of the options listed

Flat fee, including 8 hours waiting time (£300) England

Flat fee unlimited (£375) England

Flat fee, including 8 hours waiting time (£400) Scotland , Wales or NI

Flat fee, unlimited waiting time (£475) Scotland , Wales or NI

The VIP Rate (£500) + Travel charges anywhere in the UK

Twins- Flat fee, including 8 hours waiting time ((£350) England

Twins- Flat fee, unlimited waiting time (£425) England

Payment Section

After Submitting this form you will be directed to our payment page where you can pay for your selected services on-line.

You can Pay us in one of the three ways:

1- Through PayPal
2- By Debit/ Credit Card
3- By On-line Banking

We recommend the On-line Banking as there are no fees involved. Barclays Bank, Account Number: 03134474, Sort Code: 20-92-63, Go2clinic Limited

Terms and conditions

For full details please see our terms and conditions on:

https://go2clinic.co.uk/terms-and-conditions/

Declaration

I have read and understood the terms and conditions of Go2clinic Limited above and I understand that by submitting this form I will be legally bound by it. If I am signing on behalf of the expecting mother, I, the undersigned confirm that I have permission and authority from her and fully understand and accept the terms and conditions of Go2clinic Limited.

Signature: Please Print your name in the opposite box and we will treat that as your signature.

Date Time

MM / DD / YYYY

Terms and Conditions