Step #1: Client Info

First and Last Name

Status:

Currently pregnant Delivered recently, umbilical cord saved (send storage and next steps ASAP) Delivered, umbilical cord frozen (with or without placenta) Umbilical cord already dried

Phone Number

Address (ONLY OPEN TO UNITED STATES ADDRESSES)

Address Line 2 (ONLY OPEN TO UNITED STATES ADDRESSES)

City, State, Zip Code (ONLY OPEN TO UNITED STATES ADDRESSES)

Baby’s Birthdate/Due Date (YYYY-MM-DD)

Preferred Method Of Contact:(required)

Phone Call Text Email

Would you like photos of the umbilical cord and/or keepsake creation process?(required)

Yes No

Would you like to be tagged on social media in photos/video of your keepsake creation process? (Facebook, Instagram, Tiktok available)(required)

No Yes (enter social media information at next step)

Preferred social media platform and Name/Username below:

If referral or other, please specify:

Keepsake Preference Shape: Options can depend on length of umbilical cord provided. (required)

Heart (standard) Custom (enter specifics below)

Keepsake Color Finishing: (required)

Is this keepsake for an angel baby (pregnancy/infant loss)?

No Yes Other (please enter more information below)

Anything else you’d like me to know? (custom request, allergies, sensitives, news about baby, etc.)

Gift Certificate? Enter the code from gift certificate below:

Terms & Conditions #1: I confirm that I am knowingly free of HIV/AIDS, Hepatitis, and any other blood-borne pathogen/disease/contraindication that could make services not recommended. I chose services for my own personal, spiritual or cultural beliefs, at my own free will. I understand the nature and potential risks involved and related to blood-borne pathogens/handling an umbilical cord; otherwise; that I hereby assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with handing umbilical cord and otherwise using this service.(required)

Agree

Terms & Conditions #2: I understand services and fees are for the preparation of umbilical cord, not for the sale of the umbilical cord itself. I give permission for my umbilical cord to be transported/handled/processed by U Cord Keepsakes into chosen products/methods/services. I do not hold U Cord Keepsakes and all affiliate parties/owner for transportation/shipping mishaps. I will abide by cooling/storage/packaging/shipping instructions.
(required)

Agree

Terms & Conditions #3: I understand that final product(s) will vary from those shown as each umbilical cord is unique in size, shape, texture, blood vessels, etc. I give permission for photos/videos of umbilical cord/keepsake to be taken at any stage of the process and used as desired marketing/social media. I understand shipping and/or completion timeframes may vary due to a variety of factors.(required)

Agree

Terms & Conditions #4: I agree the balance of services/products must be paid in-full before shipping kit is sent/services rendered. Refunds: If for any reason umbilical cord keepsake processing is no longer recommended for your situation or if parents are unable to obtain umbilical cord, a refund will be given (minus $50 shipping/shipping kit cost). Full refund may be granted before shipping kit is sent/services rendered, partial refund may be granted depending on stage of shipping kit/preparation at time requested, no refund will be granted once services have been completed. Completed products may be held for failure of completed payment.(required)

Agree

Terms & Conditions Acknowledgement: I acknowledge that I have read the terms/contents above. I understand, accept, and agree to abide by the terms hereof.(required)

Agree

Thank you for your response. ✨