Placenta encapsulation booking form
When is baby’s due date?
Street Address Line 2
State / Province
Postal / Zip Code
Will this be your first baby?
How many baby’s are you having?
2 - Twins
What hospital are you having your baby? If birthing at home write address.
Have you informed your care provider about keeping your placenta?
Do you smoke, if so how many per day?
Have you tested positive for group B strep? (GBS)
Haven’t been swabbed yet
How did you hear about lotus lactation & placental encapsulation?
Please select what method of placental encapsulation you are interested in?
Raw method $275 inc GST
Traditional Chinese method. (TCM) $275 inc GST
Half raw, half TCM - $50 extra
Would you like a placental tincture separately?
Umbilical keepsakes come free with placental encapsulation. Would you like a free keepsake?
I just want the umbilical keepsake $30
Would you like a placenta print?
Yes please $50
I take a photo of your placenta for my records, would you like me to email/ or message you a picture?
Do you consent for me to take a picture of your placenta and use for advertising and media?
Yes, that’s ok
Please text me on 0410 496 310 to further inform of your booking. I only process one placenta at a time and adhere to strict cleaning and disinfecting between each placenta. Once booking is confirmed a $50 non refundable deposit is required. Do you agree?
Some placentas may be sent to pathology for testing after birth. If this occurs, unfortunately I can't process your placenta. The $50 deposit required at time of booking is non-refundable.
Do you agree to the terms and condition above?
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