Placenta Encapsulation Booking Form
Thank you deeply for entrusting Canberra Placenta Services to process your precious placenta. I will handle your baby’s first home with the utmost respect through each step of the service. If you have any particular requests which will better align my service to your cultural or spiritual beliefs, please let me know and I will happily incorporate it where possible.
Your name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Where are you giving birth?
*
Package drop off address / Postal addres
*
Street Address
Street Address Line 2
City
Suburb
Due date
*
 -
Day
 -
Month
Year
Date
Name and mobile number of your birthing partner who will meet me for placenta collection at the entrance into the hospital:
*
Method of encapsulation (Raw or TCM - details of both can be found on my website under “products”. Please note TCM is the only option when GBS infection is present):
*
Are you interested in learning about a Placenta Tincture? This personalised remedy offers long-term support, especially beneficial after your capsules are finished. 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 can be found in Gallery.
*
Would you like a complimentary placenta print? (A3 watercolour paper)
*
Would you like an image of your placenta sent to you via text?
*
Have you had to take any medications or supplements during your pregnancy? If so, would you list which ones please:
*
Are you planning on a water birth? When you reach the third stage of birthing the placenta, it is important that the placenta is delivered out of the pool. The warm condition of the water makes it the perfect breeding ground for bacteria. The midwives usually get you to climb out of the water after baby has arrived anyway so that they can monitor blood loss after the placenta is delivered.
*
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.)
*
Please review the following information regarding conditions that may contraindicate placenta encapsulation. These are for your awareness; you are not required to confirm any of these conditions with me. If you have any uncertainties or questions, feel free to discuss them with us. Active Infections: HIV/AIDS, Hepatitis B or C, Group B Streptococcus (GBS) infection, Infections of the placenta or amniotic membranes during labor (e.g. chorioamnionitis), Other active infections such as Lyme disease, C. difficile, MRSA, Listeriosis, Syphilis, Chlamydia, Gonorrhea, Urinary Tract Infections (UTI), Vaginal Yeast Infection, Endometritis, Endocarditis, Meningitis, Cystitis, Substance Use During Pregnancy: Smoking tobacco or use of illicit drugs. Placental or Uterine Conditions: Placental anomalies requiring hospital testing, Choriocarcinoma (cancer of the placenta), Other Considerations: Human Papillomavirus (HPV) infection Note: Only active infections are considered contraindications. For example, a past syphilis infection that has been successfully treated is not a contraindication to encapsulation.
*
I’ve read and understand the above contraindications to encapsulation.
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 birthing partner to send me a text to let me know when your placenta is ready for collection. Your birthing partner will need to meet me for collection infront of the building you’re located in. Placenta collection hours are 6:30am to 3:00pm. If baby arrives in the middle of the night, feel free to text and I will collect in the morning.
*
Yes, I understand.
Refund Policy: Refunds are on a case by case basis. There are very rare circumstances where a maternal illness is not picked up until day 2/3 postpartum, this is an issue because these rare illnesses affect your placenta. If this occurs and I have already completed the encapsulation process, I will only provide a refund of 50%. Please let me know if you have to be readmitted to hospital for any reason. Not all illnesses will impact 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 complimentary 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
Book me in 🤍
Should be Empty: