Letter of AgreementDescribing Placenta Encapsulation Services, Limits & Fees
Name (First & Last)
Partner Name (First & Last)
Client Cell Number
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Place Giving Birth
Estimated Due Date
Do you have any blood borne illnesses (HIV, Hepatitis, STD’s etc)?
Placenta Encapsulation Description:
Placenta encapsulation is the process of preparing the mother’s placenta after the birth of her baby. The purpose of placentophagy, the ingestion of the placenta, by the mother is to reintroduce beneficial vitamins, minerals, hormones, and other nutrients to her body following labor and birth to help restore a more balanced body function, increase breastmilk production, shorten healing time, increase maternal energy levels, and provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period.
Limitations and Disclaimer:
Stork & Sprout Encapsulation Specialist are not a licensed medical professional and they are not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are promised. Benefits will vary from person to person. Many of the ascribed benefits are well supported by evidence based research; but none have been evaluated.
You understand that the act of ingesting placenta in any form has not been tested, nor approved by the FDA, and you ingest them at your own risk. The services offered are not intended to diagnose or treat any condition. By choosing to utilize the services you take full responsibility for researching and using the remedies. Furthermore, by signing below you release Stork & Sprout and all independent contractors from any and all liability for any affects you may experience after choosing to take the capsules.
Stork & Sprout Placenta Encapsulation Specialists prepare the placenta according to Traditional Chinese Medicine principles. Gently steam the placenta, slice it thinly, and dehydrate it. When it is completely dry, it is powdered and encapsulated. Stork & Sprout Placenta Encapsulation Specialists maintain carefully sanitized equipment, and have completed training in blood borne pathogens and carry out proper cleanliness and preparation precautions to ensure the highest quality of placenta encapsulation possible.
It is your responsibility to notify your Stork & Sprout Encapsulation Specialist as soon after the birth as possible to make arrangements for pick-up of your placenta. Failure to do so may result in delayed placenta preparation and may cause spoilage of the placenta, which could render it unusable for encapsulation. It is your responsibility to inform Stork & Sprout of any known blood borne illnesses or other health issues that may put us at risk of infection through contact with bodily fluids, such as HIV, Hepatitis, or STIs. It is your responsibility to discuss release of your placenta from the hospital, and to ensure its storage in a cooler, refrigerator, or freezer. There may be circumstances under which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your care provider sending your placenta to Pathology for further examination. Other conditions, such as signs of maternal infection during labor, may mean that consuming your placenta will not be beneficial to you. If in doubt, I will consult with you before proceeding.
The fee for Placenta Encapsulation is $350, which includes the preparation and encapsulation of the placenta, a storage container for capsules, written instructions for storage and handling, and guidelines for taking your capsules. An umbilical cord keepsake is also provided where possible. Payments may be made in advance via square or cash. If not paid in advance payment must be made with cash when pick up of placenta.
In the event your placenta is unavailable to you (e.g. sent to Pathology and not released) or if you change your mind and choose to terminate this contract prior to releasing your placenta Stork & Sprout will refund the amount of $300, keeping $50 as a non-refundable retainer.
I/We have read everything describing the services provided by Stork & Sprout and agree that it reflects the discussion we had with a member of the Stork & Sprout team. By entering my name below I agree to services from Stork & Sprout.
By entering your name below you have read and understand to the above description and agree to services from Stork & Sprout.
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