Placenta Encapsulation Booking Form
Please complete the form below to book this service.
If you have any questions please do not hesitate to contact me. :)

Christa Buckland
BHlthSc (Health Promotion)
Doula, Childbirth Educator, Hypnobirthing
0422 229 312
christa@naturalbirthconnection.com
www.NaturalBirthConnection.com

Email address *
Full name *
Your answer
Your date of birth: *
MM
/
DD
/
YYYY
Your mobile number *
Your answer
Residential Address: *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Name of birth partner *
Your answer
Your birth partner's mobile number *
Your answer
Birth partner's relationship to you? *
Birthing at: *
Care provider: *
Required
Care Provider Name (if applicable)
Your answer
Is this your 1st, 2nd, 3rd etc. baby? *
Have you used encapsulation services before? *
Why have you chosen to encapsulate your placenta? *
Your answer
Please note, I cannot encapsulate if you have a blood-borne virus. Please advise if you have any of the following conditions: *
Required
Which method of preparation do you prefer? *
As part of my service, I provide keepsake photos of your placenta. Do you give permission for me to use these photos on my website, social media pages and/or promotional material?
Is there any important information you wish me to be aware of?
Your answer
How did you hear about my service? (select all that apply) *
Required
Payment can be made by direct deposit (preferred) or PayPal.
$100 non-refundable retainer is required upon booking. The remaining fee is due no later than 36 weeks.

Direct Deposit Details:
Bank: ANZ
BSB: 012-556
A/C: 587550123
Name: Christa Buckland

PayPal: If you wish to pay by credit card, please click here for the PayPal link: www.naturalbirthconnection.com/payments
You can also pay directly to my PayPal account: christa.buckland@live.com

Terms and Conditions
The service:
The service I provide is to prepare your placenta using the raw or TCM method. It is your choice whether you consume the capsules. The risks and benefits of placenta consumption are not fully understood. The evidence for placenta encapsulation is still emerging however there is anecdotal evidence of benefits. I cannot guarantee the effects that the capsules will have on you. If in doubt, please consult your care provider.

Pick up of your placenta:
I endeavour to pick up your placenta within 4 hours of the birth, however this depends on a number of variables and may not always be possible. It is your responsibility to store the placenta correctly until I come.

Method of encapsulation:
The TCM Method is recommended if the mother experiences an infection during the birth. Please advise me when I pick up the placenta.

On some occasions, it is not possible to encapsulate the placenta. For example,
- if the placenta is heavily stained with meconium
- if the placenta has not been properly handled and stored after birth
- if the placenta has been taken to pathology after the birth
- if the mother has a blood borne virus such as Hep B, Hep C or HIV/AIDS
YOU MUST ADVISE ME IF ANY OF THESE CONDITIONS OCCUR.

Fee and inclusions:
The fee for this service is $300, or $200 if booking another service.
This includes:
- encapsulation of your placenta
- placenta print
- cord keepsake
- digital keepsake photo
- pick up/drop off (depending on location)

Pick up of your placenta and delivery of your capsules is included in your fee for clients birthing at Campbelltown Hospital, Liverpool Hospital or Sydney Southwest Private Hospital and who live within 30 mins of my home in Campbelltown. Additional charges apply if you are birthing or live further than this.
$30 if pick up OR delivery is further than 30 minutes
$50 if BOTH pick up and delivery is further than 30 minutes

Payment Terms:
A $100 non-refundable retainer is required on booking.
The remaining fee is due NO LATER than 36 weeks.
Your booking will be cancelled if the remaining fee is not received by this time.

Refunds:
The $100 retainer is not refundable under any circumstances.
Refund (of the remaining fee) CANNOT be given after the encapsulation process has begun.
Refund (of the remaining fee) CANNOT be given for change of mind.
Refund (of the remaining fee) is given solely at my discretion.

Please check the box below to acknowledge that you have read and understand the above terms. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms