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Brisbane Placenta Encapsulation Booking & Agreement Form
Use this booking form if you are birthing at RBWH, Mater Private/Public South BNE, North West, Wesley, Greenslopes or Home Birthing in Brisbane. If you are birthing at Redcliffe, Caboolture or Sunshine Coast - please use the Sunshine Coast Booking form.
Full name:
Your answer
Date of birth:
MM
/
DD
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YYYY
Home Address
Please include your suburb
Your answer
Phone
Your answer
Email
Your answer
My baby's due date
Your answer
This is my:
Required
I'm having a planned Cesarean Birth
Required
I'm birthing at
Required
Name of my Private Midwife/Obstetrician or Doula
Your answer
Name of my support person (or person who might be in contact regarding my placenta)
Your answer
I'm currently taking the following medications
No need to include pre-natal vitamins or supplements. If you're not currently taking medications please write 'none'.
Your answer
I have the following allergies
Please list below or write 'none' if you have no allergies
Your answer
I have not smoked during this pregnancy
NB: Placenta Encapsulation is not recommended for women who have smoked during pregnancy
Required
Encapsulation method and placental remedies
Choose your method and remedies or get in touch if you have any questions
Required
optional extras
If you don't select any of the below options we will use clear vegetable capsules. Photos will only be sent if requested.
Pick up and delivery
Opt for what is most convenient for you, you can always change your mind
Required
I want to do placenta encapsulation because....
Your answer
How did you find us?
Required
Is there anything else you would like us to know or do you have any questions?
Your answer
Agreement
I understand that
Please check all boxes
Required
Agreement
Please check the boxes below to indicate your understanding and agreement to the following:
Required
Disclaimer
The services and products offered are not clinical or pharmaceutical in nature and have not been approved by the Therapeutic Goods Administration. As non-medical professionals, we have no authority to offer medical advice regarding prevention, treatment or diagnosis of illness or symptoms. By checking the box below you acknowledge that you understand the risks and benefits of placenta encapsulation, tincture and homeopathic remedies based on your own research and belief of the placenta’s healing and nutritional properties.
Required
Booking Confirmation
You'll receive an email confirmation of your booking within 24 hours with details to make your non-refundable $50. Once this is received your ‘Guide to Placenta Encapsulation’ will be emailed. You'll then receive a final payment reminder two weeks prior to your birthing time.
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Thank you
Thanks for taking the time to fill in this form. Please add my email address to your contacts list and if you haven't heard from me within 24 hours please email me on birthbabyhub@gmail.com

I look forward to working with you and your family

All the best
Carla

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