Placenta Encapsulation

Client Full Name ("Client")

First NameLast Name

E-mail

Phone Number

Area CodePhone Number

Preferred Method of Contact

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Place of Birth

"Due" Date

MonthDayYear

Partner's Name

Levana Birth's Placenta Encapsulator, Alyssa McKenzie (refered to as "I"), will obtain your placenta from the place of birth and/or your home and prepare it for encapsulation, and place into veggie capsules. I am independent and self-employed; I work for you.

Please be aware that as an Encapsulator:

· I do not perform clinical tasks, such as blood pressure, fetal heart checks, vaginal exams, or other medical procedures that fall under the legal definition of practicing medicine. I am there to provide only physical comfort, emotional support and advocacy.

· I do not provide information, dosages or advice concerning prescriptions, alternative medication or medical advice.

· I am not regluated by the state of Oklahoma and the process is performed in a dedicated space in my home. Though all precautions are made to keep things clean and free of cross-contact, there is always some risk involved with processing and consuming organs.

ALYSSA MCKENZIE’S CONTACT INFORMATION

Client may contact me anytime at 682.262.5805 or Levanabirth@gmail.com. I will answer your non-emergency questions/concerns/updates via phone/text/email within 24 hours. Please call your provider or 911 in an emergency. If you need to speak with me immediately always call twice and leave a message and/or text.

FAILURE TO PROVIDE SERVICE

I will make every effort to provide the services described herein. If I fail to obtain your placement due to my error there will be no charge for my services. If another encapsulator associated with Levana Birth LLC processes your placenta instead of me, the cost will remain the same and payment will be paid through me. If you choose not to contact me when your placenta is ready for pick-up services will be paid in full.

FEES

A payment of $250 is due with the submission of this contract. Fees can be paid in cash, check, or Cashapp. Other methods can be discussed if needed. Checks made payable to Alyssa McKenzie. Contracts can be scanned to Levanabirth@gmail.com.

In the event that services are given before payment is received, you will be invoiced. If 30 days pass with non-payment, a notice will be sent along with a $10 admin fee with an additional 1.5% interest rate for each month of non-payment.

Additional Questions or Comments:

I/We have read and understood this agreement describing the doula’s services and agree to its terms. I consent to the release of this and all other information pertaining to me to the doula(s) designated as backup for my birth.