Placenta Vitality Encapsulation Booking Form 2017
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 we will get back to you within 24 hours with your booking confirmation and important placenta storage information.
If you have any questions while filing out the form just give us a call on 0424578800
(First and Last)
Your Birth Partner's name
Or name of the person who might be contacting us if not yourself
This is the address we will drop off your capsules to you if you have left the hospital or if you are birthing at home. There may be a travel fee for locations outside a 30km radius of Coolum - Buderim, Nambour and Kawana Hosptials are WITHIN this radius. Caboolture has an additional travel fee, but there are options to avoid or reduce this.
Estimated Due Date (if you are due in 2018 please go here
Intended place of birth
Buderim Private Hospital
Sunshine Coast University Hospital at Kawana
Your own home
Caboulture Hospital - there is a travel fee for collection and drop off to Caboolture, we can have someone meet us half way and post your capsules back to you to reduce the travel fee
Preferred Method of Encapsulation
We suggest doing some research to see what method feels right for you. If you are undecided just check 'Undecided' and we will enclose some info about the methods when we email your booking confirmation.
Traditional Method (Based on principles of Traditional Chinese Medicine the placenta is steamed before dehydration)
Raw Start Method (The placenta is not steamed)
Undecided at the moment and will let you know later
Half Traditional and half Raw - extra $25
Capsules - Vegan or Flavoured Gelatine
Berry flavoured gelatine (not vegan)
Orange flavoured gelatine (not vegan)
Lime flavoured gelatine (not vegan)
Mint flavoured gelatine (not vegan)
A mix of all the flavours
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 $295 (professionally framed behind glass with a white mount and frame)
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 - $60 for 200ml
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service