BirthWright Placenta Remedies Booking Form
In order to secure your booking, please complete the form below. Full payment is required at time of booking and you must read and agree to the terms and conditions by typing your name and today's date at the bottom of the form as requested.
1. Mother's Full Name *
Your answer
2. Age *
Your answer
3. Address & Postcode *
Your answer
4. Mobile Phone Number *
Your answer
5. Email Address *
Your answer
6. Estimated Birth Day *
7. Is this your 1st, 2nd, 3rd+ baby? *
8. Do you have a Birth Partner? *
9. Birth Partner's Name *
Your answer
10. Birth Partner's Relationship to you? *
Your answer
11. Birth Partner's Mobile Phone Number *
Your answer
12. Are you under any medical supervision for any health conditions? Please answer 'Yes' or 'No'. If 'Yes', please provide details. *
Your answer
13. Where are you planning to give birth? (Please specify which hospital/birth centre/at home) *
Your answer
14. Where did you learn about BirthWright? (Your answer will be really helpful to us. Please specify which website/social media platform/friend's name, etc.) *
Your answer
15. What do you hope to gain from the Placenta Remedies you have chosen? *
Your answer
16. The following questions are for your own protection, so please give an honest answer: Have you ever tested positive for HIV, Hepatitis B or Hepatitis C? *
17. Have you smoked regularly during pregnancy? *
18. Is there anything else I should know? (e.g. medication, allergies, etc.) *
Your answer
19. Please make your selection from my Placenta Remedies Menu *
Raw Placenta Capsules (Simple Method) £200
Steamed Placenta Capsules (Based on the Traditional Chinese Medicine Method/TCM) £200
50/50 Raw/Steamed Capsules £250
Other, as agreed with Helen, £ TBC
Capsules (please tick one option)
20. Additional Options, including Package Options (please tick as many options as you would like)
Raw Placenta Smoothie £50
Placenta Essence for Mama & Baby £55
Placenta Tincture for Mama £75
Homeopathic Remedy for Mama & Baby £60
Mother & Baby Balm £45
Whipped Body Butter £55
Facial Oil £65
Placenta Print £10
Placenta Cord Keepsake Framed £40
Package #1 Baby & Me: Placenta Capsules: Simple or Steamed, Mother & Baby Balm, Placenta Essence, Cord Keepsake (unframed), Placenta Print £295
Package #2 Time for Mum: Placenta Capsules: Simple or Steamed), Placenta Tincture, Facial Oil, Whipped Body Butter, Cord Keepsake (unframed), Placenta Print £385
Package #3 Placenta Ever After: Placenta Pills: Simple or Steamed, Placenta Essence, Placenta Tincture, Homeopathic Placenta Remedies, Mother & Baby Balm, Facial Oil, Whipped Body Butter, Framed Cord Keepsake, Placenta Print £575
Other, as agreed with Helen, £TBC
Additional Remedies (scroll across)
21. Please enter the total price for Placenta Services *
Your answer
22. Full payment is required to confirm your booking. Please pay by bank transfer to the following Santander bank account: Miss HE Wright, Sort Code: 09-01-28, Account Number: 97101650, using your name as reference for my records. I confirm that full payment has been made. *
23. Terms and Conditions for BirthWright Limited 1. PRN Placenta Remedy Specialists provide placenta services including placenta encapsulation, raw placenta smoothies, placenta essences, placenta tinctures, placenta prints and the arrangement of homeopathic placenta remedies. 2. PRN Placenta Remedy Specialists have been trained and certified by a PRN accredited training provider to provide placenta encapsulation services to the public. PRN does not insure Placenta Remedy Specialists and the Client’s relationship is solely with the Specialist and not with PRN. 3. The TCM process of encapsulation used by PRN Placenta Remedy Specialists is based on Traditional Chinese Medicine. 4. Placenta encapsulation itself is experimental in nature and whilst the benefits of consuming the placenta post-birth are based on research studies, articles and testimonials from new mothers this research is ongoing and PRN does not give any warranty or representation that these benefits are guaranteed. 5. Clients who choose to utilise these services take full responsibility of their own health and for researching and using the remedies provided in this service. 6. The Client agrees that PRN or PRN Placenta Remedy Specialists are not liable and do not take responsibility for any results or effects the Client may experience before, during or after consuming the placenta unless resulting directly from the negligence of the Specialist. 7. PRN recommends placenta capsules are for the Client’s own use only. 8. PRN Placenta Remedy Specialists will not perform placenta encapsulations for Clients who have evertested positive for HIV/AIDs, Hepatitis B and/or Hepatitis C. 9. All methods of decontamination and disinfection of equipment used by PRN Placenta RemedySpecialists are practiced to Government guidelines and regulations. Placenta Smoothie blenders are‘one use’ only and are disposed of after each Client. 10. The Specialist retains ownership of any photographs taken of the Client’s placenta which may be usedanonymously for educations, advertising and promotional purposes. The Client will inform the Specialist if she does not wish photos to be taken of her placenta. 11. Your PRN Placenta Remedy Specialist aims to prepare the placenta within 3 days after the birth. However we will not be held accountable should circumstance arise where the placenta encapsulation cannot be completed until an agreed date and time. Please see documents 'PRN Information Guide for Expectant Mothers’, 'Placenta Chilling Instructions' and ‘Appropriate Placenta Care’ for guidelines for handling of your placenta. 12. PRN Placenta Remedy Specialists do not take responsibility for damaged or lost placentas before the placenta comes into our care. 13. Any advance payments will be refunded, if the placenta is unavailable for encapsulation, minus a non-refundable admin charge of £50 which will be retained to cover incurred costs during the time prior to and after your birth i.e. administration costs - including the specialist's time, consultations, mileage, provision/collection of ice packs, boxes and other equipment. 14. The Client agrees to store her placenta in a clean, labeled container inside a cooler box/bag on ice or in refrigerator within 30 minutes after birth of the placenta and agrees to ensure her placenta remains chilled until collection. 15. The Client agrees to contact her placenta specialist within 12 hours after birth to arrange safe collection of her placenta and/or home visit. 16. The Client will be liable for damaged property and/or equipment belonging to us should any equipment become broken and/or damaged whilst in the Client’s care. (For example our food dehydrator may be left overnight in the Client’s home during a Home Visit.) 17. The Client consents to the removal of the placenta from the hospital (or home) by the Specialist to the extent necessary for the performance by the Specialist of the placenta services. 18. Homeopathic remedies may be re-ordered via the PRN Homeopath, who will keep a 1c copy of the Client’s original sample for a period of 5 years. 19. The Client consents to the safe disposal of the original placenta sample used for their tincture, essence and homeopathic remedies unless the Client indicates in advance on the booking form that they would like the sample returned. Fees apply. 20. The Client agrees to complete an online Feedback Survey sent by email 6 weeks following the encapsulation and the Client agrees to answer the questions honestly to help provide statistics and testimonials for PRN. *
24. Please enter your name and today's date to confirm. *
Your answer
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