Placenta Truffles Contract
Thank you for your interest in my placenta services! This form also serves as your contract, so please fill in as thoroughly as possible. If you do not receive a response from me within 48 hours, please call 360-820-2439 or email
. I look forward to working with you!
Estimated Due Date
Birth Location Address
Please specify whether the location is Home, Hospital, or Birthing Center
Please enter the address you'd like your capsules/other product delivered to
Do you have any allergies?
If you answer "yes", please list below
If you answered yes to the question above, please list your allergies here (Please note! Truffles are made in a kitchen where allergens may be present)
$225 for 1 flavor included. $8 for each additional flavor
White Chocolate Blueberry
Dark Chocolate Raspberry
Dried as keepsake and returned (no charge!)
Amazing prints of your placenta made on acid free paper. Can be printed with the a non-toxic paint, or with the fluids already on the placenta (this may not last as long and could fade).
Yes, please make me one! (+$10)
No thank you!
Deposit for Services
To ensure that your due date and 28 day window (14 days before and 14 days after) is kept in my calendar, a $75.00 is due upon contract signing via Paypal. If Quincey is present, cash/check is acceptable. This $ is put toward your total bill.
I understand that $75.00 is due upon contract signing and I will pay Quincey via Paypal
I understand that $75.00 is due upon contract signing. Quincey is present, so I will pay with cash/checks due upon contract signing. Quincey is present, so I will pay with cash/check
If I am booking services with less than 14 days before my EDD, I understand that the full fee is due at the time of contract submission.
Method of Payment
Cash/US Check, deposit is due at time of contract signing. Remainder is due 14 days before due date (on call period starts at this time) Please DO NOT select this if you are signing this contract without me present.
Paypal (Quincey will send invoice (deposit is due at time of contract signing. Remainder is due 14 days before due date))
This will apply to any clients whose pickup and/or drop off locations are outside the Whatcom County. Amount will be added to invoice.
Pickup and drop off: $20.00 each, as far as Anacortes. Please contact me for addition information.
IMPORTANT! Ensure that your care provider knows that you want to keep the ENTIRE placenta.
Please read and place a check mark by EACH item, ensuring me that you read and understand all that is laid out for you. Contact me if you have any questions.
Shipping and Handling
This will apply to any clients who choose to have their truffles shipped to them and we have agreed upon this arrangement ahead of time. Amount will be added to invoice.
I am aware that I may change my choices at any time, according to the birth outcome and location
I agree that Quincey Ackerman will pick up my placenta at the place of birth
I agree that Quincey Ackerman will drop off the finished products at my home or other specified location within 72 hours of receiving the placenta, or make other suitable arrangements (express mail, retreival at another location)
I have informed Quincey Ackerman of any allergies or bloodborne pathogens I carry
I agree that it is my responsibility to inform care providers that I will be keeping the placenta, and to avoid taking the entire placenta to toxicology or treating it with chemicals
I have inquired about/completed any of the paperwork that might be required for the hospital to release my placenta to me
I agree to inform Quincey when I go into labor via any method of communication, and call/text Quincey at 360-820-2439 as soon as I can after the birth--but only after we are bonded, settled, and healthy
I agree to keep the placenta double-wrapped and immediately refrigerated or on ice--not frozen--if possible (I will freeze the placenta if the pickup date is later than 48 hours from birth)
I understand that the services offered by Quincey Ackerman are not clinical, pharmaceutical or intended to diagnose or treat any condition
I agree that as I choose to utilize these services, I take full responsibility for using the remedies at my own risk
I am aware that I may cancel this service at any time until two weeks before my due date, for any reason and I am aware that I forfeit a $50 deposit if I do so.
I have agreed to pay the sum of the amounts selected above via cash, check, or PayPal any time before the start of Quincey's on call time (unless a payment plan as been set in place, therefore within six months from completion date of this contract)
Failure to retrieve my placenta due to forgetfulness will result in no refund for services
The information on this page has not been evaluated by the Food and Drug Administration. These services I offer are not clinical, pharmaceutical or intended to diagnose or treat any condition. Families who choose to utilize the services I provide, take full responsibility for using the remedies at their own risk.
Expiration of Fees
All fees are subject to change. Once the form is submitted, you will not be subject to increasing prices. However, once this form is sent to you, fees are good for 30 days after receiving.
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