Encapsulation Booking Form

Encapsulation Booking Form

Thank you for entrusting Canberra Placenta Services with your precious placenta. Your baby’s first home will be handled with the utmost respect and care throughout every step of the preparation process. If you have any requests that align with your cultural, spiritual or personal beliefs, I warmly welcome you to share them so they can be honoured wherever possible. Due to the on-call nature of this service, bookings are intentionally limited each month to ensure every family receives timely, attentive care.
Full name

First NameLast Name
Mobile
Please enter a valid phone number.Format: (0000000000).
Email
example@example.com
Where will you be giving birth?
Delivery address (Free Canberra delivery or Australia-wide postage +$20)

Street Address

Street Address Line 2

CitySuburb
Estimated due date

DayMonthYear
Date
Birth partner / Collection contact (name and mobile number)
Which encapsulation method would you like? Both methods are professionally prepared and priced at $390.
placenta tincture

Many families choose to add a placenta tincture to preserve a small portion of their placenta for future personal use. It can be kept for years and is often chosen for periods such as weaning, the return of menstrual cycles or other significant life transitions.
Would you like to add a personalised placenta tincture for $60?
umbilical cord keepsake

A cord keepsake is included with your package. Each cord forms differently and is shaped according to its natural curve and length, making every keepsake beautifully individual.
Would you like a cord keepsake created?
placenta print

An A3 placenta print on textured watercolour paper is included with your package.
Select your finish:
Would you like a photo of your placenta?
Please list any medications, vitamins or supplements you have taken during this pregnancy:
May Canberra Placenta Services use de-identified photographs of your placenta on social media?
How did you hear about Canberra Placenta Services?
A few things to know: Your safety and your baby’s wellbeing are always my highest priorities. While placenta encapsulation is suitable for many families, there are some situations where it may not be recommended. These are uncommon, but it’s important that you’re aware of them before booking. Placenta encapsulation may not be suitable if there are certain maternal infections, an infection of the placenta or amniotic fluid during labour, certain bacterial infections, substance use during pregnancy, or if your placenta needs to remain with the hospital for further examination or testing. Successfully treated past infections are not usually a concern. If any of these situations apply to you, or you’re unsure whether they do, please don’t let this discourage you from getting in touch. Every pregnancy and birth is different, and I’m always happy to talk through your individual circumstances before making any decisions.
Collection: Please ask your support person to text me once your placenta is ready for collection. I will confirm the most convenient collection point for your hospital or birth location, so your support person doesn’t need to search for me. Collection hours are between 6:30 am and 3:00 pm. If your baby arrives overnight, you’re welcome to text me and I will collect your placenta the following morning. To help collections run smoothly, please request collection only once your placenta is ready to be handed over. This includes asking your midwife to remove it from refrigeration shortly before my arrival. As placenta processing is time-sensitive and collections are carefully scheduled throughout the day, I’m unable to wait for extended periods if the placenta isn’t ready. If collection can’t be completed on arrival, a call-out fee may apply in accordance with the refund policy.
While all placenta preparation is personally completed by Ash, there may occasionally be a trusted support assistant, Tash, who assists with collections or deliveries when additional support is needed. All support assistants follow Canberra Placenta Services handling, hygiene, and confidentiality procedures.
Refund Policy: Refunds are considered on a case-by-case basis. If a maternal or placental condition prevents safe encapsulation after preparation has begun, a partial refund of up to 50% may be provided. Partial refunds do not apply if collection cannot be completed because the placenta is unavailable on arrival, or if collection is cancelled after travel has commenced. Please let me know as soon as possible if you are readmitted to hospital after birth, as this may affect eligibility for encapsulation.
Informed Consent & Food Safety: I understand that the information provided by Canberra Placenta Services has not been evaluated by the Therapeutic Goods Administration (TGA). I acknowledge that placenta encapsulation and related products are not medical treatments and are not intended to diagnose, treat, cure or prevent any disease or medical condition. I understand that Canberra Placenta Services operates as a food preparation and complementary therapy service, and that my placenta will be prepared in accordance with applicable ACT food safety legislation and recognised food handling practices.
Should be Empty:

Encapsulation Booking Form

placenta tincture

umbilical cord keepsake

placenta print