PLACENTA SERVICES CONTRACT

Name*

First NameLast Name

Estimated Due Date:*

Date

Planned Birth Location & Address:*

What is the best address for delivery of your placenta products (pills, cord keepsake, prints, tincture)?*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

How Did You Hear About Us?:

Create your encapsulation package: (all packages come with placenta pickup and return and processing of service requested)

Base Placenta Package: $250

100-200 PillsCord Keepsake

Customizable Placenta Services

$50 *Tincture$30 *Salve$10 Print (Please specify colors below)

Print Colors Request:

PHOTOGRAPHY
We sometimes take photos of your placenta for record keeping or educational purposes. Do we have permission to take photos for these purposes?
YES Initial NO Initial

MEDICATIONS
Are you taking any medications besides prenatal vitamins? If so, please list them below. blanks*

ACKNOWLEDGMENTS

Guardian Angel Midwifery does not diagnose, treat, or prescribe for any medical conditions. No specific health benefits are guaranteed, and placenta products have not been evaluated by the FDA. It is your personal responsibility to determine whether placenta supplementation is appropriate for you. These products are intended solely for the individual who has given birth to the placenta(s).

You are responsible for arranging the release of your placenta from your place of birth and ensuring it is properly labeled and stored until it can be picked up or delivered for encapsulation.
Please note: Your placenta must not be treated with alcohol, formalin, or any other preservative.
I acknowledge that the placenta will be stored in a manner that retains its freshness:
Initial*
I acknowledge that I am free of hepatitis B or HIV.
Initial*

If either mother or baby develops an infection at the time of delivery or within the following 24 hours after delivery - it is important that you let us know. Please initial that you will notify us within 24 hours if an infection is diagnosed.
Initial*
Payment Policy:
A non-refundable deposit of $50 is due upon completion of the intake form to secure your service. The remaining balance may be paid in full or in installments, but must be paid in full prior to pickup of the placenta.
We accept the following payment methods: Cash, Venmo, and Zelle
Other payment options may be available upon request. Please reach out to discuss any special arrangements.
Initial*

Refund Policy:
Guardian Angel Midwifery is not responsible for refunds if you fail to notify us for placenta pickup within the appropriate time frame, resulting in the placenta being unavailable, improperly stored, or no longer suitable for encapsulation.
In the event that the placenta is found to be unsuitable for encapsulation due to infection, contamination, or other medical concerns, a refund may be requested. Please note that refunds are not guaranteed and will be reviewed on a case-by-case basis. The initial deposit fee of $50 is non-refundable under any circumstances.
Please Note: A positive GBS swab is not an indicator that a placenta is unsafe for consumption. If you have questions or concerns regarding this topic, please reach out for further information and/or guidance.
Initial*

I understand and agree to the terms of this contract.

Name*

First NameLast Name

Signature*

Date*

Date

PLACENTA SERVICES CONTRACT

Please Initial the Following: