Placenta Encapsulation Contract
Home Address (Street, City, Zip Code)
Are you having a scheduled cesarean?
Processing Options (check all that apply)
Traditional Chinese Medicine inspired (steamed) encapsulation - $225
Raw encapsulation - $225 (Contraindicated if Group B Strep Positive)
Half steamed, half raw encapsulation - $250
Add 2oz tincture - $25
Add salve - $40
Twin placentas - add $50
Other (non-placental) products
Healing herbs for sitz baths, 5oz - $12.50
Postpartum afterpains herbal tea, 5oz - $12.50
Lactation tea, 5oz - $10
New Mom Welcome Basket ( herbals teas, sitz bath, aromatherapy massage oil, nipple cream) - $50
Delivery of processed capsules
No delivery, will pick up
Delivery for Harmony Doula clients - no fee
Delivery within 60 miles of Mtn. House, CA - $30
Delivery beyond 60 miles - Rates for delivery individually calculated at $0.50 per mile over 60
Your responsibilities as a client: (please read and check all)
Inform Teri if you are Group B Strep Positive (GBS+)
Call Teri when labor starts and again when baby is born.
For hospital deliveries, bring a gallon ziplock, cooler, and ice packs.
Inform your care providers not to contaminate your placenta with chemicals or non-bodily fluids.
If your facility requires the placenta to leave the building immediately, arrange to have it taken home.
Keep your placenta on ice after delivery, refrigerate within 4 hours of delivery.
Freeze placenta if pick-up is delayed more than 3 days after delivery.
If pathology is necessary, send a sample not the whole placenta.
Placenta samples sent to pathology are contaminated and cannot be encapsulated
Teri Nava-Anderson is committed to providing you with the services described in this Agreement. She make every effort to preserve your placenta. If she is unable to preserve it, due to her own failure to pick it up within a week of delivery and you chose not to have it processed at that time, a full refund will be made. If she is unable to preserve it due to contamination after delivery or unhealthy tissue, a partial refund will be given. If she is unable to preserve it due to your failure to inform her of delivery or failure to properly store it before pick-up, no refund will be given.
I understand and agree.
I understand and acknowledge that there are no current laws in California prohibiting me to take my placenta home with me. I also understand that choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural.
I understand that my placenta has been handled and encapsulated according to OHSA and California State Food Safety and Handling standards, and has been cleaned, cooked, dehydrated and put into pill form in a sanitary and sterile work space. Upon receiving my placenta capsules from Teri Nava-Anderson, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules. I do not Teri Nava-Anderson responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment), and understand that I am choosing to have her encapsulate my placenta in her home office. I put full trust and acknowledgement that my placenta is being handled in a sanitary and safe environment.
I am able to provide Teri Nava-Anderson with documentation showing that my blood, body and/or body fluids have been tested for STD’s (including HIV and Hepatitis B) and the results were negative (non-reactive). I understand and trust that Teri Nava-Anderson will retain these records in a safe and confidential manner.I understand that upon receiving the pills, Teri Nava-Anderson is not liable to myself or any other person who ingests or utilizes my own placenta capsules, tincture or salve.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service