Placenta Encapsulation Booking Form

  • Placenta Encapsulation Booking Form

    And/Or Placenta Preparation for Burial ©️TheFreoDoula This form and its contents are the intellectual property of The Freo Doula. Unauthorised use or duplication is strictly prohibited.
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  • Estimated Due Date*
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  • Which service would you like to book in for?

  • Please Choose Your Encapsulation Method-
  • Burial Preparation Method (if choosing burial preparation only )
  • Select a Collection & Delivery option -*
  • Where are you birthing? / placenta to be collected from*

  • Add a Placenta Transportation Kit – $30 Take the stress out of transport. This clearly labelled, collapsible cooler bag is compact enough to pack with your birth items and is provided on loan. It’s purpose-designed for safe placenta storage and easy collection—no bulky eskies, no fuss.Sent to you upon booking.*
  • Please choose your preferred type of Capsules*
  • Would you like a complimentary umbilical cord keepsake? Please see examples on instagram*
  • What shape would you like the keepsake? * (please note this may change according to cord length)

  • Would you like to add any extras?*
  • Do you have a support person? (Encapsulation only)
  • Is your OB/Midwife aware of your decision to encapsulate?
  • Is this a twin placenta*
  • Have you ever tested positive for HIV/AIDS, hepatitis A, B or C or syphilis?*

  • Do you carry any other bloodborne diseases that you are aware of?*
  • Do you consent to photos being taken of your placenta throughout the process?*
  • If yes, can I post these photos on The Freo Doula's social media pages? Keeping you, as a client, anonymous?*
  • How did you hear about The Freo Doula?*

  • Terms & Conditions – Placenta Encapsulation Services

    Please read carefully before booking. By proceeding with your booking, you agree to the following terms:

    1. While placenta encapsulation is supported by anecdotal reports and emerging research, I, The Freo Doula, do not guarantee specific results or outcomes. I am not responsible for any side effects or reactions that may occur from consuming placenta products.

    2. Clients are responsible for their own health decisions and are encouraged to conduct personal research on the methods and potential benefits of placenta encapsulation before proceeding.

    3. It is the client’s responsibility to ensure their placenta is released from the birth facility for collection.

    4. Proper storage is essential. Clients must follow recommended guidelines to ensure the safe preservation of the placenta prior to collection. Clients are responsible for providing a cooler bag and ice brick unless a transportation kit has been arranged.

    5. I take pride in using a natural and respectful process. However, in accordance with hygiene standards, some medical-grade sanitising agents must be used to maintain a safe and sterile environment.

    6. I am not liable for placentas that are damaged, lost, or contaminated before being received into my care.

    7. Placenta products are intended solely for the person who birthed the placenta. I do not take responsibility for any health or legal implications that may arise from others consuming the capsules.

    8. Clients must disclose any known bloodborne infections at the time of booking, including but not limited to: Hepatitis B, Hepatitis C, Syphilis, and HIV/AIDS.

    9. For health and safety reasons, I am unable to process placentas from individuals who have tested positive for any bloodborne diseases listed above.

    10. Clients agree to keep their placenta in their possession at all times following birth, to avoid it being sent to pathology or contaminated, which would render it unsuitable for encapsulation.

    11. Once placenta capsules or products are returned to the client, The Freo Doula is no longer liable for their use, storage, or effects, including if the products are consumed by anyone other than the client.

    12. Payment Terms:

    Full payment is required at the time of booking. This secures your place in my calendar and ensures I’m able to reserve space around your estimated due date.

    Bank Details:

    Tara Ravaei

    BSB: 066121

    Acc: 10122030

    Please include your full name and due date as the payment reference.

    13. Refunds will not be issued except in cases of early pregnancy loss (prior to 26 weeks), miscarriage, or stillbirth. If your placenta is taken for lab testing and deemed unfit for encapsulation, a partial refund will be provided- the total amount paid less a $100 deposit/booking fee. No refund is offered if you change your mind about encapsulation or the placenta was not handled and stored appropriately. 

    14. If I become unwell or unable to encapsulate your placenta for any reason, I will arrange a trusted back-up specialist. If no back-up is available, your placenta can be safely frozen until encapsulation is possible. If the service cannot proceed at all, a full refund will be issued.

     

     

     

     


    © The Freo Doula – Tara Ravaei | 2025

    If you have any questions about these terms, please reach out before booking — I’m happy to walk you through them gently and clearly

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