Placenta Vitality Encapsulation Booking Form for Homebirths

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Please fill in the form below, read through the Responsibilities and Small Print, and note your preparation preferences along with any information relating to your pregnancy that we should be aware of. We respect your right to privacy and assure you that all answers are held in strictest confidence.

After you submit your form please check your spam for your confirmation email with important PLACENTA STORAGE and information.

If you have any questions while filing out the form just give us a call on 0424578800

Name *

(First and Last)

Phone Number *

Email Address *

Your Birth Partner's name

Or name of the person who might be contacting us if not yourself

Home Address *

This is the address we will collect your placenta from and return your capsules to. There may be a travel fee for locations outside a 30km radius of Eumundi.

Estimated Due Date (please check if it is asking for MONTH or DAY first as depending on your browser Google Forms sometimes uses American dating where the month comes first) - If you are unsure just confirm your date in the note section at the end of this form :) *

YYYY

Preferred Method of Encapsulation *

$345 Placenta Vitality now only offers the Traditional method of encapsulation, but we can help you find someone who will do the Raw method for you if that is your preference.

Traditional Method (Based on principles of Traditional Chinese Medicine and in alignment with Food Safety standards the placenta is steamed before dehydration)

Please send me a referral of someone who does the Raw method

Capsules - Vegan or Flavoured Gelatine

Vegan

Berry Flavoured Gelatine (not vegan)

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Placenta Prints

Two prints on 300gsm watercolour paper (blood prints, no added colouring or paint, outlined with fine point black pen).

Yes please - $25 for two

Cosmos/Nebula Art Watercolour

Not all of us want to have an actual placenta print on our wall, so a Cosmos/Nebula Art Watercolour piece is a beautiful way of celebrating your placenta and the part it played in nourishing your baby. And there is something a little cosmic about the whole miracle of growing a Human Being inside you! A blood print is taken and then traced to get the outline of your placenta. From that we will create a unique cosmos and inside add the stellar constellation of the star sign that your baby was born under. SIZE: A3 paper (so if framed the frame will be a little larger) PAPER: 300gsm Archers Cold Pressed watercolour paper PAINT: Schmincke and Windsor and Newton Artist's quality paint. (You may give colour preferences if you have them).

Framed $345 (professionally framed by Red Dog Framers, behind glass with a white mount and frame)

Unframed $205

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Placenta Tincture

Tinctures are a great way of continuing the benefits of placenta remedies beyond the postnatal period. You will receive a 200ml bottle, a dosage bottle and dosage guidelines. **200mls is a lot, you will only use a few drops at a time, so the bottle should last you to your menopause!

Yes please - $65 for 200ml

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