Blooming in Adelaide Placenta Encapsulation Booking Form

Blooming in Adelaide Placenta Encapsulation Booking Form
Mother Details
Full Name*

First NameLast Name
Client Residential Address / Postal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Your Estimated Due Date*

MonthDayYear
Date
Birthing Place

Home within 30km of AdelaideWomen's & Children's HospitalLyell McEwin HospitalGawler HospitalFlinders Medical CentreAshford HospitalBurnside HospitalCalvary HospitalOutside Metro, Eg Mount Barker/Murray Bridge ***
PLEASE NOTE: I do not charge a travel fee to collect within 30km radius of Adelaide hospitals. However if more than 30km from GPO additional travel fee applies as below. Regional areas by request.

If you are outside of the metro area, please contact me to arrange.

Please note that you will be required to sign a hospital release of medical tissue form to enable collection from your birthing hospital.

The hospital cannot legally retain your placenta for 7 days, they will tell you this to deter you from encapsulation.

Placenta needs to be kept on ice or refridgerated between birth and collection.

Once this form is submitted I will make contact with you:

1. to confirm you booking

2. to provide a receipt for your deposit

2. to provide instructions on contacting me to arrange collection

Please feel free to text/email/phone if you have any concerns or questions, or if you have any special requests.

Thank you

Regards Rebecca
Which Package Do you wish to book

Gold Package $300 (includes pick up & return)Silver Package $250 (includes pick up and return by express post)Bronze Package $230 (parent to deliver and collect to our premises)Additional Travel fee of $30 Silver / $60 Gold as per above
A $50 deposit is required to be paid when you book, with the balance due upon completion and prior to return

Payment via:

PAY ID 0414 701 412

MY PAY ID NAME: R KUBENK

Reference: your name
Signature

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