Placenta Service Request

Client Name*

First NameLast Name

Estimated Due Date or Baby's Birth Date*

Date

Place of Birth

Email*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

How'd you hear about us?*

Please list any allergies below:

Have a Safe & Happy Postpartum

My Products

Placenta Packagepick up/drop off placenta pills

$300.00

Placenta Package Pluspick up/return, placenta pills, tincture, salve, and print

$375.00

Placenta Print add on12x18 keep sake print of your placenta

$30.00

Tincture add on4oz placenta tincture

$30.00 Quantity

Salve add on2oz placenta salve

$30.00 Quantity

Total

$0.00

We sometimes take photos of placentas for record keeping or education. Identifying information is never shared. Do you give permission for photos of your placenta to be used as described?*

yesno

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Please read and sign below

--------------------------------------------------------------------------------------------CLIENT RESPONSIBILITIES
It is the client’s responsibility to notify Mother Moonstone as soon as possible after the birth of your baby so that we may schedule medical courier pickup and your services. Failure to do this can result in placenta deterioration and/or spoilage which may decrease the potential nutrients, hormones and other benefits, or render your placenta unusable for the purposes of encapsulation.

It is the client’s responsibility to discuss and secure release of the placenta with your medical care team and birth facility prior to labor/birth.

It is the client’s responsibility to inform Mother Moonstone of medical information (blood -borne illnesses, viral and bacterial infections, HIV/AIDS, Hepatitis, STDs, etc) that are contagious by contact with blood or other bodily fluids, such as amniotic fluid

DISCLAIMER
Mother Moonstone is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, or medical doctor and is therefore unable to diagnose, treat, or prescribe for any health condition. Benefits of placentophagy are supported by anecdotal evidence and there is research underway, but this has not been evaluated by the FDA. Services and fees are for the preparation and encapsulation of your placenta, not for sale of the pills. Placentophagy, (as it pertains to this contract agreement, is for supplementation and is intended only for ingestion by the person who birthed the placenta and not for their family members, friends, or other individuals),this is a natural nutritional supplement and as such cannot be promised or guaranteed to produce specific results. Placenta tinctures are made with alcohol and are not to be provided to children. Families who choose to utilize the services take full responsibility of their own health and for researching and using the remedies and understand Mother Moonstone makes no claims of medical treatment.

FEES
*All services are nonrefundable once we have possession of your placenta. If you cancel services prior to Mother Moonstone having possession of your placenta, your payment will be refunded, minus a $75 fee.

By signing below I (client) agree the the terms listed above*

Name

First NameLast Name