Placenta Services Agreement & Booking Form
Mothers First & Last Name *
Your answer
Mothers Contact Number *
Your answer
Email address *
Your answer
Approximate due date *
Your answer
Partners First & Last Name *
Your answer
Partners Contact Number *
Your answer
ADDRESS - Number, Street & Suburb *
Your answer
Are you a first time mother *
Required
Place of Birth (Home / Name of Hospital) *
Please indicate where you are having baby in Metro Area
Why have you chosen to Encapsulate? *
Your answer
How did you find us? *
Personal Referral (please give persons full name so we can send a thank you)
Your answer
Other website (please provide)
Your answer
Have you made your wishes about the handling and removal of your placenta clear to your primary care giver? *
I understand that there is no guarantee on the amount of capsules I will receive after my placenta has been processed. *
Are you aware if you are carrying any transmittable diseases? (Such as Hepatitis B, C, Syphilis, HIV 1 & 2, HTLV 1 & 2). *
Are you Strep B positive? *
Have there been any other medical issues or complications during the pregnancy? *
Required
If yes above please provide details
Your answer
I understand that the placenta capsules should not be taken in heat conditions *
Or taken with the presence of pathogenic factors, when a fever is present, eg the flu or mastitis.
I understand that due to the delicate balance of the hormones, capsules should NOT be taken in the event of a new pregnancy. *
Please advise if you smoked during your pregnancy. *
As the placenta cannot filter out the heavy metals, (eg if the mother has smoked nicotine or illicit drugs) during the pregnancy), the placenta could potentially contain high enough heavy metals to make it unsafe for consumption.
Do you consent photos being taken of your encapsulation process for display on my website or facebook page.
No names or identifying features will be given. Your privacy will be protected at all times.
Feedback *
Would you be happy to complete a survey on the your experiences taking placenta capsules
Required
The fee for this basic service is $250. Deluxe Service is $300. Outside metro will incur an aditional collection/transportation fee. Details can be found on our website. A deposit of $50 is payable when you Book *
Banking Details are included below.
PAYMENT DETAILS : CBA BLOOMING IN ADELAIDE - BSB 065 165 ACCOUNT 1030 4626
A confirmation of your booking & receipt will be posted to you once the deposit is paid.
Your answer
Do you have any additional requirements / requests
Your answer
DATE *
MM
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Form Completed by *
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