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 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
Mobile
Please enter a valid phone number.Format: (0000000000).
Email
example@example.com
Where are you giving birth?
Canberra address for free package drop off / postal address for additional $20

Street Address

Street Address Line 2

CitySuburb
Due date

DayMonthYear
Date
Support person name (collection contact) and mobile:
Method of encapsulation. Both options are professionally prepared and offered at $390: •Raw Method — $390 •Traditional Chinese Method (TCM) — $390
For mothers wanting ongoing support, a placenta tincture offers a lasting way to continue drawing on your placenta’s nourishment. Many families choose to include one so they have gentle hormonal support once capsules are finished, and during weaning, the return of cycles, or emotionally demanding seasons. Add a personalised 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 an image of your placenta sent to you via text?
Please list any medications or supplements taken during your pregnancy:
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.)
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)
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.
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.
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.
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 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.
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.
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Encapsulation Booking Form

umbilical cord keepsake

placenta print