Placenta Services Agreement
Thank you for choosing Placenta Services! I firmly believe in the value of Placenta Remedies in postpartum recovery and beyond, and will prepare your remedies with utmost care. Please fill out the following form to ensure I have the information I need to prepare safe and useful remedies for you and have them back to you in a timely manner. If any questions arise, please do not hesitate to contact me, I am here to help!
Sign in to Google
to save your progress.
Partner's Name, if applicable
Estimated Due Date
Planned place of birth
Colchester Regional Hospital
IWK Health Centre
South Shore Regional Hospital
St. Martha's Regional Hospital
North Cumberland Memorial Hospital
Valley Regional Hospital
Cape Breton Regional Hospital
Do you have any sexually transmitted or bloodborne infections including Hepatits, HIV, Syphilis, or HTLV?
Have you had any health concerns or complications with this pregnancy? Are you taking any medications?
Remedies & Keepsakes Chosen
You may select as many as you like.
$175 Placenta Powder (not encapsulated)
$200 Placenta Encapsulation (pills)
$30 Placenta Salve/Ointment
$30 Placenta Prints
Complimentary Cord Keepsake
Responsbilities of Client and Placenta Services Provider
Your responsibilities include having the placenta from the hospital, ensuring proper storage of the placenta until I take possession of it, and notifying me promptly so we can arrange pick-up, drop-off, or other transportation of the placenta to me. Please be sure to read my guide to release, care, and transport. My responsibilities include maintaining client confidentiality, upholding the highest standards of cleanliness, safety, and quality of professional placenta preparation services within 48 hours of birth, and returning your remedies to you. Please note that I do visit friends & family out of town from time to time. If your birth coincides with a weekend away, remedy preparation may be delayed by 24-48 hours (Please initial below to indicate that you have read and agree to the above)
Please select your situation below.
I am a local client.
I am an out-of town client and will be transporting the placenta to Truro via Maritime Bus Courier Service.
I am an out-of-town client and will have someone deliver the placenta to you in Truro.
I live in a region where Maritime Bus Service does not operate (we can arrange transport by another courier)
Fees and Refund Policy
A $50 deposit is required upon signing this agreement, the remainder of the balance being due at the time of remedy preparation. In the event your placenta cannot be released to you, any fees paid including the deposit will be refunded in full. There will be no refund and payment will be due in full once I have begun remedy preparation. Payment may be made via email, cash, or cheque. (Please initial below)
Limitations and Disclaimer
I am not a licensed medical professional and I am not able to diagnose, treat or prescribe for any health condition. Services fees are for the preparation of your placenta remedies, not for the sale of the capsules, tincture, or salve. Although the theories behind the reported benefits of placenta remedy use by the mother are supported by ongoing research and centuries of safe use, placenta remedies have not been evaluated by Health Canada. It is your responsibility to determine whether using placenta remedies may be of benefit to you. It is important to note that there may be circumstances under which your placenta can not be used to prepare remedies. Abnormalities of the placenta may result in the need for the placenta to be sent to Pathology for further examination. Other conditions, such as signs of infection in the mother during labour, may mean that consuming your placenta will not be beneficial to you in remedy form. In these circumstances, your placenta may still be able to be used in other ways if you so choose (prints, cord keepsake, burial) if your placenta remains untreated by formalin or other lab chemicals. (Please initial below)
Please enter your full name and today's date below as an electronic signature. Thank you for entrusting me with your placenta, I will prepare your remedies and keepsakes with the utmost care!
I have read, understood, and agreed to the above information. I accept the responsibility of gaining possession of my placenta, and notifying New Roots Birth Services the day of or the morning after my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below I authorize the release of my healthy placenta to New Roots Birth Services for the purposes of placenta remedy and keepsake preparation for my own personal use.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service