BirthWright Placenta Remedies Booking Form
In order to secure your booking, please complete the form below. Full payment is required at the time of booking, unless agreed otherwise. Please read and agree to the terms and conditions by typing your name and today's date at the bottom of the form.
1. Mother's Full Name *
2. Age *
3. Address & Postcode *
4. Mobile Phone Number *
5. Email Address *
6. Estimated Birth Day *
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7. Is this your 1st, 2nd, 3rd+ baby? *
8. Do you have a Birth Partner? *
9. Birth Partner's Name *
10. Birth Partner's Relationship to you? *
11. Birth Partner's Mobile Phone Number *
12. Are you under any medical supervision for any health conditions? Please answer 'Yes' or 'No'. If 'Yes', please provide details. *
13. Where are you planning to give birth? Please tell us the name of the hospital / birth centre; or at home. *
14. Where did you learn about BirthWright? Your answer will be really helpful. Please tell us which website/social media page/friend's name, etc. Thank you! *
15. What do you hope to gain from the Placenta Remedies you have chosen? *
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.) *
19. Please make your selection from my Placenta Remedies Menu *
Raw Placenta Capsules (Simple Method) £225
Steamed Placenta Capsules (Based on the Traditional Chinese Medicine Method/TCM) £225
50/50 Raw/Steamed Capsules £250
Capsules (please tick one option)
20. Additional Options, including Package Options (please tick as many options as you would like)
Placenta Tincture for Mama £75
Placenta Essence for Mama & Baby £65
Homeopathic Remedy for Mama & Baby £60
Mother & Baby Balm £45
Facial Oil £65
Whipped Body Butter £55
Raw Placenta Smoothie £75
Placenta Print £15
Placenta Cord Keepsake Framed £50
Package #1 Baby & Me: Placenta Capsules: Simple or Steamed (for 50/50 add £25), Mother & Baby Balm, Placenta Essence, Cord Keepsake (unframed), Placenta Print £325
Package #2 Time for Mum: Placenta Capsules: Simple or Steamed (for 50/50 add £25) Placenta Tincture, Facial Oil, Whipped Body Butter, Cord Keepsake (unframed), Placenta Print £425
Package #3 Placenta Ever After: Placenta Pills: 50/50 Simple & Steamed, Placenta Essence, Placenta Tincture, Homeopathic Placenta Remedies, Mother & Baby Balm, Facial Oil, Whipped Body Butter, Framed Cord Keepsake, Placenta Print £625
Other, as agreed with Helen, £TBC
Additional Remedies (scroll across)
21. Please enter the total price for Placenta Services *
22. Full payment is required to confirm your booking. Please pay by bank transfer to the following Santander bank account: Miss Helen Elizabeth 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 Placenta Services 1. BirthWright provides placenta services including placenta encapsulation, raw placenta smoothies, placenta essences, placenta tinctures, placenta prints, cord keepsakes, placenta oil, cosmetics and the arrangement of homeopathic placenta remedies. 2. Helen Wright, the Founder of BirthWright, has been trained and certified by an accredited training provider (IPEN), to provide placenta encapsulation services to the public. 3. The TCM process of placenta encapsulation, also known as the Steamed process, used by BirthWright Placenta Services 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 BirthWright does not give any warranty or representation that these benefits are guaranteed. 5. Clients who choose to utilise these services take full responsibility for their own health and for researching and using the remedies provided in this service. 6. The Client agrees that BirthWright is not liable and does 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 BirthWright. 7. BirthWright recommends placenta capsules are for the Client’s personal use only. 8. BirthWright will not perform placenta encapsulation for Clients who have ever tested positive for HIV/AIDs, Hepatitis B and/or Hepatitis C. 9. All methods of decontamination and disinfection of equipment used by BirthWright are practiced to Government guidelines and regulations. Placenta Smoothie blenders are single use only and are disposed of after each Client. 10. BirthWright retains ownership of any photographs taken of the Client’s placenta which may be used anonymously for education, advertising and promotional purposes. The Client will inform BirthWright if she does not wish photos to be taken of her placenta. 11. BirthWright aims to prepare the placenta within 3 days after the birth. However, BirthWright will not be held accountable should a circumstance arise where placenta encapsulation cannot be completed until an agreed date and time. Please refer to the documents sent to you by BirthWright, which are also included in your Collection Kit: 'Appropriate Placenta Care' and 'Placenta Storage Guide for Parents' for guidance on the safe handling and storage of your placenta after birth. 12. BirthWright does not take responsibility for damaged or lost placentas before the placenta comes into our care. 13. If the placenta is unavailable for collection after birth for any reason, the full Collection Kit must be returned to BirthWright as soon as possible - either in person or by courier such as UPS/Hermes - at your own expense. A refund will then be issued, 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 a 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 BirthWright, 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 BirthWright to the extent necessary for the performance by BirthWright of the placenta services. 18. Homeopathic Placenta Remedies may be re-ordered via BirthWright's dedicated 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 encapsulation and the Client agrees to answer the questions honestly to help provide statistics and testimonials for BirthWright. *
Required
24. Please enter your name and today's date to confirm. *
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