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Placenta Encapsulation Booking Form
IPEN- The Independent Placenta Encapsulation Specialist
Certified Placenta Specialist
www.MotherBirthMountains.com
* Required
Email address
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Your email
What is your Full Name
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Your answer
Contact Phone Number
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Your answer
Home Address
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Your answer
What is your postal address if different from above?
Your answer
Although you will need to phone me to notify me when you are in early labour, it is usually a support person whom I will meet with to collect the placenta directly from. What is the name of your Birth Support Person & their contact phone number?
What is your estimated due date?
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Are you planning a hospital or home birth
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Hospital
Home
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Name & contact details of your Care provider e.g.: Midwife
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Your answer
Have you informed your Midwife of your capsules
Yes
No
Clear selection
Does your Care provider support your decision
Yes
No
Clear selection
For our own protection, we MUST have an honest answer to the following questions. Have you ever tested positive for HIV, Hepatitis B or Hepatitis C?
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Yes
No
Do you smoke?
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Yes
No
Why are you interested in Placenta Encapsulation?
Your answer
Have you ever suffered from excessive baby blues or post natal depression before?
Your answer
You will be given a placenta care form to give to your care provider in advance to your birth. All placentas are collected by hand & must be contained in an air tight lidded container with your name on it & placed into a cooler bag or esky within a certain time frame & stored on ice or with ice packs for collection? An easy way to do this is to make sure you pack the needed items into your labour bag in advance. Do you agree to ensure the placenta will be appropriately stored for collection.
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YES
No
Required
Please select to specify the service you require & leave blank any service you do not require.
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TCM (Traditional Chinese Medicine) Encapsulation $320.
Dried Raw Encapsulation $320.
Tincture $80
Placenta Print $20
Essence $60
Umbilical Keepsake is included at no extra cost
We have spoken & made arrangements for a Smoothy $40.
We have spoken & made arrangements for Slithers to be an option $40
Required
Capsule Delivery Options
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I choose to have capsules delivered by hand at original collection point at an arranged time & location at no extra cost.
I choose to have my capsules returned directly to my postal address via express next day delivery with Australia post for the cost of only an additional $25.
Locations for collection of Placenta options are, Mount Tomah, Lithgow or Blackheath. My Placenta will be appropriately stored & the area I would like to arrange for collection is
Mount Tomah
Lithgow
Blackheath
Clarence
You are my Birth Doula & will be taking the placenta with you
Clear selection
Tinctures & Essences have a longer processing time. The process timeframe for tinctures is 6 weeks & Essences take 4 weeks to process. If you are having a Tincture and/or Essence made please select one of the following options
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I choose to collect my Essence &/or Tincture in the Lithgow area directly from my Encapsulation Specialist, who will phone me when the tincture &/or essence is ready for collection, to make collection arrangements.
I choose to have my Tincture &/or Essence sent directly to my postal address via next day delivery service with Australia post once my Tincture &/or Essence has been processed, for an additional cost of $5. per Tincture &/or Essence.
I have not ordered a Tincture &/or Essence
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