New Client Information for Placenta Encapsulation
Today's Date *
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Mother's Full Name *
Your answer
Partner's Name
Your answer
Street Address *
Your answer
City & State *
Your answer
Zip Code *
Your answer
E-Mail Address *
Your answer
Best Contact Phone Number *
(Please list best phone and alternate number if applicable)
Your answer
Estimated Due Date *
(The date you reach 40 weeks according to your health records.)
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Are you expecting: *
Name of location you plan to deliver your baby. *
Your answer
Birth Location's Full Address *
(Street Address, City, State, Zip Code)
Your answer
Does your caregiver know that you plan to keep your placenta? *
Have you had any complications with your pregnancy thus far? If yes, please expalin *
Your answer
Why did you decide you wanted to use your placenta for postpartum health? *
(Please be as detailed as possible.)
Your answer
Please check the following items you are planning to purchase: *
Please see the products page for description and price list for further information.
Required
Waiver of Liability *
I (Mother) understand and acknowledge that in accordance to the Florida Drug and Cosmetic Act, Chapter 499 Florida Statutes, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments, or symptoms. I am choosing to consume my placenta due to my personal beliefs. I also understand that my placenta specialist is not a doctor or pharmacist and is acting as a personal chef. I acknowledge that Laci Watson, aka First Coast Birth Services, LLC, has provided me with information about both the benefits and risks of placenta encapsulation, and I have read all included documents. I understand that my placenta will be handled and encapsulated according to OSHA's and Florida Food Safety and Handling's standards, and will be prepared in a sanitary and sterile work space by an trained Placenta Encapsulation Specialist. Upon receiving my placenta capsules, I waive any and all rights to hold Laci Watson, aka First Coast Birth Services, LLC, responsible for any undesired side effect of consuming the capsules. I understand that upon receiving my pills, Laci Watson, aka First Coast Birth Services, LLC, is no longer liable for any other person(s) ingesting my placenta capsules, or any other placenta edible. I agree to these terms and conditions:
Refund Policy *
Once placenta preparation has begun or your Encapsulation Specialist has come to your home, no refund is available. If your placenta is not able to be prepared or consumed for a medical reason beyond your control, then, a 50% refund will be issued. If your placenta is not able to be prepared or consumed due to your negligence of care after the birth process (improper storage, improperly refrigerated, left at room temperature too long, etc.) no refund is available. In order for you to obtain a partial refund, you are required to notify your Encapsulation Specialist of the birth of your baby within 48 hours of your baby's birth. Your partial refund will be granted within 7 business days. These terms and conditions are subject to change at any time.
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