Placenta Encapsulation Booking

Name *

First Name Last Name

E-mail *

Your Estimated Due Date *

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I am planning a scheduled c-section

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Pick Up Address *

Street Address
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City	State / Province
Postal / Zip Code	Country

Capsules Delivery Address *

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

Phone Number *

Area Code Phone Number

Partner Name

First Name Last Name

Partner Phone Number

Area Code Phone Number

How did you hear about our Placenta Encapsulation Services? *

The Birthing Field Website Referral from Chrysalis Birth Referral from another Professional Magazine / Expo / Advertising Word of mouth Internet Search

Do you have a history of any of the following? *

Blood Borne Pathogens (HIV, Hepatitis, Syphillus, STI's etc.) Depression / Anxiety Group B Strep Latex Allergy Food Allergy I have none of these

Details of above if applicable

Are there any significant health or pregnancy issues you wish to inform us of?

How would you like your placenta prepared? *

Steamed-dehydrated, encapsulated, $325 Raw-dehydrated, encapsulated, $325 Part raw, part steamed-dehydrated, encapsulated, $325 Placenta Prints ($40) Cord Keepsake (included free)

Is there anything else we need to know in relation to your placenta encapsulation?

I HAVE A CODE

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Please carefully read the following contract, terms and conditions before signing and completing your booking below.

Placenta Encapsulation Services

Your Placenta Specialist’s Obligations
Your Placenta Specialist will:

§ collect your placenta from your birthing place (home or hospital) within 24 hours of your call;

§ prepare the placenta according to your requirements within another 48 hours.

§ honour and respect your placenta during the preparation;

§ prepare your placenta in a safe and hygienic manner;

§ return the capsules to you to the delivery address in Cairns as per our agreement within 72 hours of collection of placenta. Delivery outside of Cairns may take additional postage or delivery time. Addtional travel fee of $30/hour is applicable to transport of placenta outside of the Cairns region. Return postage (if required) of capsules $15.

Your Obligations
§ You will call your Placenta Specialist as soon as possible after birth to organise collection, between the hours of 8am to 7pm. Texts can be received 24 hours.

§ You will organise with your health professional’s storage of the placenta in a sealed container (not only a plastic hazardous waste bag) that is to be placed in the fridge (not freezer) within 4 hours of birth. Placentas must be placed in a bag and then inside a sealed container.

§ Please advise your health professionals that your Placenta Specialist is authorised to collect it for you.

§ Please notify your Placenta Specialist of your arrangements prior to collection.

§ A $50 non-refundable deposit is due immediately to ensure your booking.

§ Full/balance payment is due prior to or upon collection of the placenta from your birthing place.

§ It is your responsibility to inspect the placenta and deem it useable for the purposes of encapsulation.

§ You acknowledge that your Placenta Specialist is not a medical practitioner and as such do not give medical advice about consumption of your placenta.

§ You acknowledge that the placenta capsules and preparations are only to be ingested by you.

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Placenta Encapsulation Deposit $ 50.00 AUD

I have read the above contract, terms and conditions. *

I understand and agree with all terms herein

Signature *

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Placenta Encapsulation Booking with Deposit