Placenta Encapsulation Booking Form

Name*

First NameLast Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Estimated Due Date

DayMonthYear

Which service would you like to book in for?

Placenta EncapsulationPlacenta Preparation for BurialBoth Encapsulation & BurialOther

Encapsulation Method (if choosing Encapsulation only) - This is a completely personal choice & clients have many reasons for choosing one over the other. Please contact me anytime to discuss the differences if needed. I would recommend the TCM method if Meconium is present or if tested positive for GBS

Raw $275- Your placenta is cleaned, prepared, dehydrated and then encapsulatedTCM (Traditional Chinese Method) $300 - Your placenta is cleaned, prepared and steamed with nourishing herbs before being dehydrated and then encapsulated.Half/Half $290 - Half Raw & Half TCM. The TCM capsules can be taken first for hormone stabilisation & then the raw capsules taken later for increased energy.

Burial Preparation Method (if choosing burial preparation only )

Raw $100- Your placenta is lovingly cleaned for burial with antiseptic & astringent Herbs. Placed into a biodegradable bag And is delivered in a biodegradable kete basket with ceremonial prayer & instruction.Dehydrated $150 -Your placenta is lovingly cleaned for burial with antiseptic & astringent Herbs. Dehydrated for 24 hours and powderised before being placed into a biodegradable bag And delivered in a biodegradable kete basket with ceremonial prayer & instruction.

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 option - for Encapsulation **IMPORTANT** - youmust choose option 3 or 4 if you are having RAW burial preparation and encapsulation together.

Option 1 - You organise for the placenta to be delivered to me (via support person/partner etc) in the Fremantle area. I express post the finished capsules back to you within 72 hours* (may be longer if over a weekend) - Add $10.95 postageOption 2 - I come to you to collect the placenta .(***Please ensure your support person can meet me at the entrance***) I express post the finished capsules back to you within 72 hours* (may be longer if over a weekend) - Add $65 Zone 1 -Add $75 Zone 2 & 3Option 3 - I come to you to collect the placenta.(***Please ensure your support person can meet me at the entrance***) I deliver the finished capsules in person within 72 hours post birth* (may be longer if over a weekend) -Add $80 Zone 1 -Add $90 Zone 2 & 3Option 4- You organise for the placenta to be delivered to me. You collect the finished product from me upon completion. (No extra charge)

Select a Collection option - For Burial preparation only (no Encapsulation)

Option 1 - You organise for the placenta to be delivered to me in the Fremantle area. I deliver the finished product back to you within 48 hours* (may be longer if over a weekend). -Add $20 Zone 1. - Add $30 Zone 2 & 3Option 2 - I come to you to collect the placenta . I deliver the finished product back to you within 48 hours* (may be longer if over a weekend) - Add $40 Zone 1 -Add $50 Zone 2 & 3Option 3 - You organise for the placenta to be delivered to me. You collect it upon completion. (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, Attadale Private 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 - $25 This makes it easy! A clearly labelled, collapsible cooler bag that you can store in with your labour things. This is on loan only - sent out at booking and designed to store your placenta safely and clearly labelled for collection. No hassle with bulky eskys!

YesNo

Please choose your preferred type of Capsules

Veggie Capsules (Vegan friendly)Berry flavoured Capsules (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)

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?*

Terms & Conditions

Please read the Terms and Conditions of the service.

1. Benefits of placenta encapsulation are based on research, although I, The Freo Doula,do not guarantee results or benefits, and do not take responsibility for any side effects the client may experience during or after consuming their placenta capsules.

2. Clients take responsibility for their own health and have done their own research as to inform themselves on the benefits and methods of placenta encapsulation.

3. It is the clients responsibility to get their placenta released to them from the birth facility.

4. It is the clients responsibility to follow recommended storage measures to ensure optimal preservation of their product. Client is responsible for providing cooler bag and ice brick.

5. I take pride in the natural process used in encapsulation, however some disinfecting chemicals must be used to ensure a sanitised and hygienic environment.

6. I do not take responsibility for damaged/lost placentas before coming into The Freo Doulas posession.

7. I only advise for the person whose placenta is used in the placenta capsules to consume the product. I do not take responsibility for legal/health implication of others consuming.

8. Testing and results of Hepatitis B & C, syphilis and HIV/AIDS must be disclosed at booking.

9. For health reasons, I cannot process the encapsulation of a placenta of a person who has tested positive to Hepatitis C, Hepatitis B, HIV/AIDS, Syphilis or any bloodborne disease.

11. Client agrees to keep placenta in their sight at all times to ensure it does not go to a lab where it will be contaminated by chemicals or other harmful substances rendering it unsafe for consumption.

12. Client understands that upon receiving placenta pills and products, The Freo Doula is no longer liable, including but not limited to any other persons ingesting client’s placenta.

13. IMPORTANT: Full payment must be made at the time of booking. This is the easiest way to avoid chasing money up when you have a newborn. Please make payment into account with your full name & due date

Tara Ravaei

BSB: 066121

Acc #: 10122030

14. Upon your payment, I will reserve your spot on the calender, and will not make other reservations around your estimated due date. Refunds cannot be given,unless unplanned events occur(only including a miscarriage,still birth or early term birth before 26 weeks). In the event your placenta is taken away for lab testing it will be deemed unfit for ingestion, a refund will be made, less 10% of the full fee

15 .If I am unable to provide placenta services due to illness or am otherwise incapacitated, all efforts will be made to send a back-up specialist. Contract will then be taken over by the back-up specialist. If I am unable to provide services and no back up specialist is available, the placenta can be frozen and encapsulated as soon as possible. If after this the service can still not be carried out, a full refund will be given.

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

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