Booking Form

Placenta 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 or spiritual beliefs, I 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.
Your name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Where are you giving birth? *
Package drop off address / Postal address*

Street Address

Street Address Line 2

CitySuburb
Due date*

DayMonthYear
Date
Support Person (collection contact) name and mobile:*
Method of encapsulation - both options are professionally prepared and offered at $390: •Raw Method — $390 •Traditional Chinese Method (TCM) — $390*
Are you interested in learning about a Placenta Tincture? This personalised remedy offers long-term support, particularly supportive once your capsules have been completed. Available for $60:*
Would you like a complimentary umbilical cord keepsake? If yes, would you prefer the cord in the shape of a swirl, a heart, a double heart, an infinity symbol, baby’s first initial or “love”, examples are available in the Gallery.*
Would you like a complimentary placenta print? (A3 watercolour paper)*
Would you like an image of your placenta sent to you via text?*
Please list any medications or supplements taken during your pregnancy:*
If you’ve had previous pregnancies, have you suffered from placenta accreta, increta or percreta? (Placenta fusing and imbedding into the wall of your uterus)*
Do you have a history of uterine scarring from conditions such as endometriosis or previous cesarean sections? (Note: Uterine scarring can increase the risk of placenta accreta, where the placenta attaches too deeply into the uterine wall.)*
Important Health Information For your safety, there are some medical conditions that may prevent placenta encapsulation. These are uncommon, but it is important you are aware of them. You are not required to disclose any information here. If you are unsure, you are always welcome to discuss this with me privately. My priority is always the safety and wellbeing of both mother and baby. Encapsulation may not be suitable in cases of active maternal infections (such as HIV, Hepatitis, or Group B Strep), infection of the placenta or amniotic fluid during labour, certain bacterial infections, substance use during pregnancy, or placental abnormalities requiring hospital testing. Successfully treated past infections are typically not a concern. Your placenta is prepared in accordance with recognised food safety and handling guidelines.*

I have read and understood the health information above.
Do you consent to Canberra Placenta Services using images of your placenta on social media?*
How did you hear about Canberra Placenta Services?*
Collection: Please ask your support person to send me a text once your placenta is ready for collection. Your support person will need to meet me at the front entrance of your hospital or birth location. Collection hours are 6:30am to 3:00pm. If your baby arrives overnight, you are welcome to text and I will collect in the morning.*

Yes, I understand.
Collection Readiness and Timely Handover: Please request collection only once your placenta is ready for immediate handover. This includes asking your midwife to remove the placenta from refrigeration prior to my arrival. Once collection has been confirmed and travel has commenced, the booking may be cancelled if the placenta is not available or if collection can not be completed promptly on arrival. Due to time sensitive handling requirements and scheduled collections, I am unable to wait for extended periods. If collection cannot be completed, a call out fee will apply and any remaining balance will be refunded in accordance with the refund policy.*

Yes, I understand
Refund PolicyRefunds 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 due to the placenta being unavailable upon arrival or if collection is cancelled after travel has commenced.Please inform me as soon as possible if you are readmitted to hospital postpartum, as this may affect eligibility for encapsulation.*

Yes, I understand
Informed Consent, Food Safety and Disclaimer: I acknowledge and understand that the information provided by Canberra Placenta Services has not been evaluated by the Therapeutic Goods Administration (TGA). I understand that services and items prepared by Canberra Placenta Services are not medical treatments and are not intended to diagnose, treat, cure, or prevent any disease, illness, or medical condition, whether physical or mental. I understand that Canberra Placenta Services operates as a food preparation and complementary therapy service and prepares items in accordance with applicable ACT food safety requirements and food handling standards. I acknowledge that these services are not provided as regulated medical or pharmaceutical services. I confirm that I am choosing to engage with these services voluntarily, at my own discretion, and accept full responsibility for the use of any items prepared.

Yes, I understand and provide my informed consent
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Placenta Encapsulation Booking Form