Graceful Birth Doula Services Inc.
Placenta Encapsulation Registration / Agreement
Email address *
Address *
Your answer
City *
Your answer
Full Name *
Your answer
Cell Phone Number *
Your answer
Partners Name *
Your answer
Doula
Your answer
Partners Cell Number
Your answer
Estimated Due Date *
MM
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YYYY
Place of Birth *
If hospital, which one *
Your answer
Are you interested in having a tincture made? Additional $50 charge + HST *
Are you interested in having Salve made? Additional $30.00 +HST
Salve is a cream that is made with soothing oils and herbs.. It can be used for soothing wounds such as the perineum, c section wounds, rashes, etc. some woman also use it on their nipples. (please see disclaimer at bottom of form)
Are you interested in having a print made? Additional $15.00 + HST
Are you interested in having perineum herbal bath soak made? $20/package + HST
Do you have allergy to ginger or lemon or red thai chilli peppers? *
Are you vegetarian or vegan?
Please specify
Your answer
Do you have a history of depression and/or anxiety? *
Do you have any known blood borne diseases? *
(ie. Hep B or C, HIV, etc.)
Please specify
Your answer
Are you Group B Strep Positive
Which method of preparation would you like me to use? *
Please note: Mother’s choosing the Raw Food method agree that by checking below you are aware that by choosing this method you have elected that your placenta not be steamed and therefore I cannot insure that there will be no bacteria present in the final product if you specify you want it at a lower temperature than 160°F (71°C). *
Required
In the event that Graceful Birth cannot process my placenta immediately (unforeseen circumstances, another client has given birth shortly before you, etc), I grant permission to a back up Certified APPA encapsulator on our team to process my placenta. *
How did you hear about Graceful Birth placenta encapsulation service?
DISCLAIMER-Your placenta specialist is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, homeopath or medical doctor. Benefits of placenta encapsulation are supported by maternal experience and have not been evaluated or approved by the Health Canada. Placenta Encapsulation or placentophagy is intended solely for ingestion by the mother who has birthed the placenta(s) and not for her family members, friends, or other individuals and is not guaranteed to produce specific results. The services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services take full responsibility of their own health and for researching and using the offered services. Your placenta specialist makes no guarantee as to capsule efficacy, but does guarantee the highest quality of service. By entering into this agreement I release Graceful Birth Doula Services Inc. from all damages or causes of action, either law or in equity, which I have or acquire or which may occur to me as a result of using Graceful Birth Doula Services Inc. I intend this to be a complete release and discharge Graceful Birth Doula Services Inc. from all liability whatsoever. *
I agree that I am paying for the encapsulation service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition. No refunds for services will be given. My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS. My care provider and I have determined that my placenta is healthy. The placenta has been handled in a manner appropriate for safe food preparation since the birth.
I understand that in order for my placenta to be processed safely, I must keep the placenta cold (at a temperature less than 4 degrees Celsius) within 2 hours of the birth. If the placenta has been left out longer than 2 hours, I understand that the encapsulator may not be able to safely process my placenta. *
Full cost of services is $299.00 plus HST. A $50.00 + HST ($56.50) non-refundable retainer is required to complete your registration. Please email transfer to grace@gracefulbirth.ca. Please note that our services include communication and administration services. Your retainer secures your spot and therefore if cancelled is a loss of business for Graceful Birth. *
When Grace picks up my placenta, I will pay her the balance as follows:
Call or text message me at 416-804-9617 after the birth to arrange a time to pick up the placenta. Please call between 8am and 8pm. If you are not able to contact me within two days of the birth and the placenta has been appropriately refrigerated since the birth, please freeze the placenta until you are ready for pickup. Encapsulation and capsule delivery generally takes 2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed. *
Permission is granted for your specialist to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Food Safety and Handling standards. Your placenta will be cleaned, steamed (if indicated above), dehydrated and put into capsule form in the sanitary and disinfected work space indicated above. The specialist is not responsible or liable for any issues preventing provision of the services that are beyond her control (ex. car accident, detainment, placenta sent to Pathology Dept., etc). *
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