Placenta Services Intake and Agreement form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Doula

Provider

Phone Number

Area CodePhone Number

Due date*

Date

Planned place of birth:*

Address : Need for placenta pick up*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I am not a licensed medical professional such as a care provider or physician and I am not able to diagnose, treat or prescribe for any health condition. Fees are for the service of encapsulating your placenta, not for the sale of the capsules. Each women will react to her placenta capsules in different ways. Some of the ascribed benefits of placenta consumption are supported by ongoing research, however these benefits have not been evaluated or approved by the United States government or the Food and Drug Administration. It is your responsibility to determine whether using placenta capsules can be beneficial to your well-being postpartum. *

Client's Initials

Client Responsibilty: It is your responsibility tocompensate for services no later than two weeks before yourestimated due date. If this amount is not received at this time, servicescannot be guaranteed.It is your responsibility to notify me within 3hours of the birth so that we can work together to make arrangements for pickupor drop off. Failure to do so may result in delayed placenta preparation andencapsulation and may cause decreased potency of nutrients, hormones, and otherbeneficial attributes of the placenta. Improper storage of the placenta priorto pick up or drop off may result in spoilage. It is your responsibility todiscuss release of your placenta from the facility where you will give birthduring the prenatal period and to ensure proper storage of your placenta in arefrigerator or cooler. This can be done by placing the placenta on ice untilit can be retrieved for preparation and encapsulation. *

Client's Initials

It is also your responsibility to inform me of any known blood borne illness(es)or other health issues (such as HIV, hepatitis, etc.) that could place me or any others who may come in contact with your bodily fluids (specifically maternal and fetal blood as well as amniotic fluid) at risk. Some specific sexually transmitted diseases such as Hepatitis or herpes may preclude me from offering placenta encapsulation in my home. *

Client's Initials

My Responsibilities: My responsibilities include maintaining client confidentiality, committing to preparing and returning your capsules within 72 hours of receiving your placenta (usually within 36-48 hours), and upholding the highest standards of cleanliness, safety, and quality of professional placenta preparation services.*

Client's Initials

It is important to understand that there may be circumstances in which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending a sample of your placenta toPathology for further examination. Once the placenta has been released toPathology, I will not be able to encapsulate without an additional waiver.Other conditions, such as signs of infection in the mother during labor, maymean that consuming your placenta could be harmful to your health. I willalways consult with you prior to making a choice on whether or not yourplacenta is viable for ingestion. It should be possible to claim your placentaafter caesarean surgery. It is important that you let me know if you have anyhealth concerns or conditions which may affect the health of your placenta orthe health and safety of anyone who may come into contact with your placenta. *

Client's Initials

Refunds: In the event your placenta is unavailable to you (ex. sent to Pathology and not released) or if your placenta has been contaminated with a bacterial infection please notify me as soon as possible, you will be entitled to a refund of travel compensation only if the trip to your hospital has not already been made. If you choose to terminate this contract due to change of mind within 7 days of your estimated delivery date, then you are eligible for reimbursement of travel compensation with proper notice to me. If I have already taken possession of your placenta and you choose to not go forward with services, I will return your placenta to you for disposal and no refund will be given. There will be no refund once preparation has begun, even if you choose not to take delivery of the finished capsules. In the event that placenta is taken to pathology and still released, we can switch to non consumptive preparation instead and no refund will be given *

Client's Initials

Placenta Liability Waiver:

I understand and acknowledge that in accordance to my state laws, by 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 acknowledge that my placenta specialist has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta has been handled and encapsulated according to OSHA and State Food safety and handling standards, and has been cleaned, cooked, dehydrated, and put into pill or chocolate form in a sanitary and sterile work space.

Upon receiving my Placenta capsules/chocolates from my placenta specialist, I waive any and all rights to hold the specialist responsible for any undesired effects of consuming my placenta. This may include an oversupply in milk, hormonal shift, anxiety or sleeplessness. These side effects are rare but have been reported. I agree to contact my placenta specialist if any of these occur. I do not hold my placenta specialist responsible or liable for any transport mishap that is beyond their control (ex. Car accident, detainment, etc. ) And understand that I am choosing to have the specialist encapsulate my placenta in the specialist's homes.

I put trust and faith that my placenta specialist has been training correctly to prepare placenta remedies. I will provide my placenta specialist with recent blood documentation stating that I have been tested for STDS and only negative results guarantee services. If my blood results indicate hepatitis, HIV/AIDS or herpes virus, I understand that I will allow my Placenta Specialist to prepare in my home, using most of my own supplies including a dehydrator. Universal precautions for sanitizing are the same with each client. I understand and trust that my Placenta Specialist retains blood work records for each client and that I am protected.

Client's Initials

YesNo

If yes, please specify.

Mama Bear Package $375Chocolates $275Capsules $275Raw/frozen smoothies prepped $175Placenta Burial Preparation $175Twin Placenta Encapsulation: $375 ($275 base price + $100 additional prep fee for processing two placentas).

Traditional Chinese Medicine Method (Steamed with Lemon, Jalapenos, & Ginger)RawSteamed

Half Capsules/Half Chocolates $554 oz Placenta Tincture $55Placenta Salve $35Placenta Print (1 print) $25Placenta Photo (3 digital photos) $451 Placenta Smoothie immediate postpartum $75

Blood PrintColored Print (Gel food coloring used)

YesNo

If yes, please specify.

YesNo

If yes, please specify.

YesNo

If yes, please specify.

What are you hoping to experience with taking the encapsulation?

How did you hear of Gentle Love Doula?

We would love to send a thank you gift.

I have read, understood, and agreed to the above information. I accept the responsibility of gaining possession of my Placenta and notifying my placenta specialist within 3 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below, I authorize the release of my healthy placenta to Cynthia Garcia for the purposes of placenta encapsulation and keepsake preparation for my own personal use. *

Client Initials

I understand that the turnaround time can vary between 3-5 business days. *

Clients Initals

I understand and agree to pay an additional travel fee if pick up location is more than 35 miles from Gentle Love Doula's location. *

Client's Initials

I understand that upon receiving my Placenta capsules/chocolates, my Placenta Specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules/chocolates. *

Printed Name

I grant Gentle Love Doula and its representatives/subcontractors the right to use photographs/videos of my placenta. I agree that Gentle Love Doula and its representatives/ subcontractors may use any of those photos for any lawful purposes including but not limited to, website/social media content, advertisements, and illustrations.I do not grant Gentle Love Doula and its representatives/subcontractors the right to use any photographs/videos of my placenta for webistes/social media content, advertisements, and or illustrations.

Date

Signature*

My Products*

Placenta Encapsulation Choice (must choose one)

Mama Bear Package

-Placenta capsules OR chocolates -(1) placenta art print -4oz tincture -Placenta Salve -Umbilical cord keepsake

$375.00

Placenta Capsules Only

Placenta Capsules -Umbilical Cord Keepsake

$275.00

Placenta CHOCOLATES only

Placenta Chocolates -Umbilical Cord Keepsake included

$275.00

Placenta Burial Prep

Placenta is prepped for burial with fresh and dried flowers. 1 print and a placenta photoshoot (3 digital photos).

$175.00

Placenta Prep for Smoothies

I will prep your placenta into individual sizes and cubes for you to use in your placenta smoothie drinks.

$175.00

Placenta Prep Add Ons (Optional)

Placenta Salve

$35.00

Placenta Print

$25.00

Placenta Photo Shoot

3 digital photos of your placenta

$45.00

1 Placenta smoothie immediate postpartum

I come to your home with my equipment, meant only for placentas and prep a smoothie for you immediate postpartum. Fruit for smoothie is included.

$75.00

4 oz Tincture

Placenta Tincture

$55.00

Half Chocolate/Half Capsules Add on

You can choose this add on to make your placenta encapsulation into half/half combo.

$55.00

Twin Placenta Processing Fee

Twin Placenta Processing: Please note this is an additional $100 fee. This covers the extra time and resources necessary for the preparation and encapsulation of two placentas.

$100.00

Travel Fee

For travel more than 40 miles from Gentle Love Doula's Location (Hearne, TX)

$50.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

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