CPS Booking Form
Email address *
First Name *
Your answer
Last Name *
Your answer
Suburb or Town *
Your answer
Street Address *
Your answer
Postcode *
Your answer
Phone number *
Your answer
Email *
Your answer
Alternative contact name and phone number
Your answer
Midwife or doula's name and phone number if you have one
Your answer
Estimated Due Date *
Where do you plan to have your baby? *
Have you informed your primary care giver about placenta encapsulation? *
Are they happy with your decision? *
Have you ever tested positive for *
please tick any POSITIVE results
Where did you first learn about placenta encapsulation? *
Please select the services you require *
*All placentas are collected by hand in a cooler bag to ensure safe transit. Please refer to information document for instructions on safe handling if you choose to deliver your placenta. Address for delivery of placenta and/or collection of capsules is Conder, full details will be supplied when booking is confirmed. If you live more than 25k outside the Australian Capital Territory, collection and delivery fees may vary, please contact Vickie to confirm costs.
Total cost *
Please show total cost of services booked. A non refundable $50 deposit is required to secure a booking, balance by cash or direct transfer is due before or upon receipt of the placenta. Transfer details will be supplied when booking form is submitted.
Your answer
Have you read the Safe Storage and Handling instructions ? *
It is important that you understand the storage requirements for your placenta. If a placenta is not properly stored it can not be processed.
Have you read and do you agree to the Terms and Conditions? *
The terms and conditions are available at www.canberraplacentaservices.com Your booking cannot be made until this document has beed read. By submitting this form you agree that all the information you have given is correct and you agree to the Terms and Conditions
Any questions or information you would like to add?
If you have any special requests, or need more information please do not hesitate to ask here, or contact Vickie on 0422 008 759
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A copy of your responses will be emailed to the address you provided.
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