New Client Information for Placenta Encapsulation
New Pill Clients Please Fill Out Form
Today's Date *
Mother's Full Name *
Partner's Name
Street Address *
City & State *
Zip Code *
E-Mail Address *
Best Contact Phone Number *
(Please list best phone and alternate number if applicable)
Estimated Due Date *
(The date you reach 40 weeks according to your health records.)
Are you expecting: *
Name of location you plan to deliver your baby. *
Birth Location's Full Address *
(Street Address, City, State, Zip Code)
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 *
Why did you decide you wanted to use your placenta for postpartum health? *
(Please be as detailed as possible.)
Please check the following items you are planning to purchase: *
Please see the products page for description and price list for further information.
Waiver of Liability *
I (Mother) understand and acknowledge that 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 with Laci Watson 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 with Laci Watson Birth Services LLC, responsible for any undesired side effect of consuming the capsules. I understand that upon receiving my pills, Laci Watson with Laci Watson 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 DUE TO 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 FOLLOWING THE BIRTH OF YOUR CHILD. 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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