Placenta Encapsulation Booking Form

Name*

First NameLast Name

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Estimated Due Date*

DayMonthYear

Which service would you like to book in for?

Placenta EncapsulationPlacenta Preparation for BurialBoth Encapsulation & BurialOther

Please Choose Your Encapsulation Method- Choosing between methods is a deeply personal decision, and each option offers its own unique support. Some clients are drawn to the energy and vitality of the Raw method, while others prefer the grounding, restorative qualities of the Traditional Chinese Medicine (TCM) approach. I’m always happy to talk through the options with you to help you choose what feels right. If meconium is present at birth, or if you’ve tested positive for GBS, I generally recommend the TCM method for its added steaming process, which offers an extra layer of safety.

Raw $275 - Your placenta is lovingly cleaned, gently prepared, and slowly dehydrated before being encapsulated. This method retains more of the placenta’s original properties and is often chosen for an energizing, uplifting effect in the early postpartum weeks.TCM (Traditional Chinese Method) $300 -Your placenta is cleaned, gently steamed with warming, nourishing herbs, then dehydrated and encapsulated. This traditional method is grounding and supportive for hormone balancing and emotional well-being — especially recommended if meconium is present or GBS positive.Half/Half $290 - Half prepared Raw, half via the TCM method. Many choose to take the TCM capsules first for hormonal support, followed by the Raw capsules later for a gentle energy boost — offering the best of both worlds in your healing journey.Placenta Powder Only $200- Your placenta is cleaned, dried, and ground into a fine powder — no capsules. This powder can be kept for ceremonial use (such as burial or planting) or added to foods, drinks, or smoothies if you prefer a more flexible way to receive its benefits.

Burial Preparation Method (if choosing burial preparation only )

Raw – $150 - Your placenta is lovingly prepared for burial using traditional antiseptic and astringent herbs. It’s placed into a biodegradable bag and gifted in a biodegradable kete basket, along with ceremonial prayer and gentle guidance for the process.Dehydrated – $200- Your placenta is prepared with care for burial using sacred herbs and then dehydrated for 24 hours. It’s wrapped in a biodegradable bag, presented in a kete basket, and accompanied by a ceremonial prayer and instructions to honor your placenta’s journey home.

I would like both Encapsulation & Burial Preparation - Please choose your methods (if applicable)

Half your placenta is steamed for encapsulation. The other half is prepared for burial. (Burial portion comes in a biodegradable traditional kete bag with ceremonial prayer and instructions) $300

Select a Collection & Delivery option -*

Option 1 – You deliver, I post back. You arrange for your placenta to be dropped to me in Fremantle (via a support person/partner). I’ll express post your finished capsules within 72 hours (may take longer over weekends). + $15.95 postage. Note : Australia Post is currently taking 3–4 days to deliver express within Perth.Option 2 – I collect, I post back. I collect the placenta from you (please ensure your support person can meet me at the entrance). Capsules are express posted within 72 hours. + $65 (Zone 1) + $75 (Zones 2 & 3) Note: Australia Post may take 3–4 days for delivery.Option 3 – I collect, I deliver back in person. I collect the placenta and return the capsules to you in person within 72 hours of birth (may take longer over weekends).+ $80 (Zone 1) + $90 (Zones 2 & 3)Option 4 – You deliver, you collect. You drop off your placenta and collect your finished capsules from me. No extra charge

Where are you birthing? / placenta to be collected from*

Zone1- King Edward Memorial Hospital / Family Birth Centre, Fiona Stanley Hospital, Bentley Hospital, SJOG Subiaco, SJOG Mt.Lawley, SJOG Murdoch -Zone 2 - Armadale Hospital, Osborne Park Hospital, Rockingham General Hospital, Glengarry Private Hospital, Swan District Hospital – additional travel fee/s applies.Zone 3 - Joondalup Hospital, SJOG Midland, Peel Hospital. additional travel fee/s applies-Home - South of the river - Collection fees apply (I use your nearest hospital as a guide)Home- North of the river - Collection fees apply (I use your nearest hospital as a guide)Other

If birthing at hospital, which hospital?

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.*

YesNo

Please choose your preferred type of Capsules*

Veggie Capsules (Vegan friendly)Berry flavoured Capsules (contain gelatin. Add $10.00)Grape flavoured Capsules (contain gelatin. Add $10.00)

Would you like a complimentary umbilical cord keepsake? Please see examples on instagram*

Yes (see next question)No

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)

Yes (see next question)NoNot Applicable

Name and Phone number of support person

Is your OB/Midwife aware of your decision to encapsulate?

YesNoNot applicable

Is this a twin placenta*

YesNo

Have you ever tested positive for HIV/AIDS, hepatitis A, B or C or syphilis?*

YesNoOther

Do you carry any other bloodborne diseases that you are aware of?*

YesNo

Do you consent to photos being taken of your placenta throughout the process?*

Yes (see next question)No

If yes, can I post these photos on The Freo Doula's social media pages? Keeping you, as a client, anonymous?*

YesNo

How did you hear about The Freo Doula?*

Facebook/InstaGoogleFriend (mention a friend that has used my service in the box marked ‘other’ for a 10% discount)Repeat ClientPerth Homebirth Group/Conscious Mothers GroupOther

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 (full amount less a 10% administration fee).

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.

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

I (insert full name) Have read, understood and agree to the Terms and Conditions as outlined.

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