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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.
Date of birth:
Please include your suburb
My baby's due date
This is my:
Sixth or more
I'm having a planned Cesarean Birth
I'm birthing at
RBWH Birth Centre
Mater Public South Brisbane
Mater Private South Brisbane
North West Private
Home - my address listed above
Name of my Private Midwife/Obstetrician or Doula
Name of my support person (or person who might be in contact regarding my placenta)
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'.
I have the following allergies
Please list below or write 'none' if you have no allergies
I have not smoked during this pregnancy
NB: Placenta Encapsulation is not recommended for women who have smoked during pregnancy
No, I have not
Yes, I have
Encapsulation method and placental remedies
Choose your method and remedies or get in touch if you have any questions
$250 Raw Method Encapsulation
$260 TCM Method Encapsulation
$270 Half Raw, Half TCM Encapsulation
$50 Placenta Tincture, 25ml dropper
$100 Placental Homeopathic Remedy, 25ml pillules
$140 Placenta Tincture and Homeopathic Remedy
$20 Placenta Blood Prints (2 x A3 size)
If you don't select any of the below options we will use clear vegetable capsules. Photos will only be sent if requested.
I'd like clear vegetable capsules please
I'd like berry flavoured gelatin capsules please
I'd like digital photos sent to my email address please
Pick up and delivery
Opt for what is most convenient for you, you can always change your mind
Personal pick up & delivery: RBWH, Mater South Brisbane, North West, Greenslopes, Wesley ($50)
Personal pick up & delivery to my home address listed above ($50)
Personal pick up (home or hospital) & delivery via express registered mail ($35)
I will organise delivery to Carla & would like my capsules posted express, registered mail (inclusive)
I will organise delivery to & collection from Carla (inclusive)
I want to do placenta encapsulation because....
How did you find us?
Placenta Services Australia Directory
Is there anything else you would like us to know or do you have any questions?
I understand that
Please check all boxes
I am responsible for informing my care provider that I intend to encapsulate my placenta.
My placenta needs to be placed in a sealed container on ice or be refrigerated within 3 hours of birth (ASAP is preferable).
I should keep my placenta with me to avoid contamination, mix-ups or it being accidentally thrown away.
Please check the boxes below to indicate your understanding and agreement to the following:
We aim to collect your placenta within 10 hours of birth so it is helpful for someone to contact us once labour begins and again when ready for pick up.
We do not determine whether your placenta should be consumed and make no guarantee of your personal results from the capsules.
Should your placenta be deemed unsuitable for encapsulation or sent to pathology and not released, you will receive a full refund of fees less your $50 non-refundable deposit.
We are on-call for you two weeks either side of your due date (e.g. not further than a 2 hour drive away). However, should your birth happen outside of those times and we are unavailable we will endeavor to organise a backup Encapsulation Specialist for you or offer a full refund of fees (including deposit). Please note – this has never happened and we will always let you know in advance if we plan to be away anytime around your birth time.
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.
I have read and understand this
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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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
I look forward to working with you and your family
All the best
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