Placenta encapsulation booking form
Name
First Name
Last Name
Partners name
When is baby’s due date?
/
Day
/
Month
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Will this be your first baby?
Yes
No
How many baby’s are you having?
1
2 - Twins
3- Triplets
What hospital are you having your baby? If birthing at home write address.
Have you informed your care provider about keeping your placenta?
Yes
No
Not yet
Do you smoke, if so how many per day?
Have you tested positive for group B strep? (GBS)
Yes
No
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 $350 inc GST
Traditional Chinese method. (TCM) $350 inc GST
Half raw, half TCM - $50 extra
Would you like a placental tincture separately?
Yes $70
No
Umbilical keepsakes come free with placental encapsulation. Would you like a free keepsake?
Yes please
No thanks
I just want the umbilical keepsake $30
Would you like a placenta print?
Yes please $50
No thanks
I take a photo of your placenta for my records, would you like me to email/ or message you a picture?
Yes please
No thanks
Do you consent for me to take a picture of your placenta and use for advertising and media?
Yes, that’s ok
No thanks
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?
Yes
No
Payment
Please transfer the $50 booking deposit to the nominated account below. Please send a screenshot of payment to 0410 496 310. Do you agree
Hospital policy
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?
Yes
No
Signature
Date
-
Day
-
Month
Year
Date
Submit
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