Placenta Encapsulation - Booking Form, Contract and Liability Waiver

Placenta Encapsulation - Booking Form, Contract and Liability Waiver

Placenta encapsulation is the act of taking a fresh, raw placenta, washing the placenta, steaming and slicing the placenta raw, dehydrating, grinding and putting the placenta powder into consumable capsules. All processes are done with respect and education of the placenta and in a sanitary environment. ZaMama business practices strict OSHA guidelines and following proper food safety standards.
Name

First NameLast Name
Estimated Due Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Planned place of Birth
Residential address for postage or delivery.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I choose to have my placenta encapsulated in the following way
I would like the following products to be made when my placenta is being encapsulated
PLACENTA COLLECTION AND DELIVERY
Payment is to be made via Direct Bank Deposit. Would you like to pay
The placenta capsules that are being prepared are for your (owner of the placenta) consumption only and are not designed to reverse medical conditions or ailments from pregnancy, to treat postpartum depression, to ensure normal milk supply or to replace medical attention.
Do you have any of the following? HIV, Hepatitis B, Hepatitis C and Syphilis. (You can find your details in your Antenatal blood records or ask your care provider)
ZaMama is not a licensed medical professional body, such as a care provider or physician and is not able to diagnose, treat or prescribe for any health condition.
Fees are for the service of encapsulating your placenta, not for the sale of the capsules.
Each woman will react to her placenta capsules in different ways. Some of the described benefits of placenta consumption are supported by ongoing research, however these benefits have not been evaluated or approved by the Australian government or the Food and Drug Administration. It is your own responsibility to determine whether using placenta capsules can be beneficial to your wellbeing postpartum.
I understand and acknowledge that in accordance to my state laws and bylaws, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural.
TERMS AND CONDITIONS ~ Clients take responsibility for their own health and have done their own research as to inform themselves on the benefits and methods of placenta encapsulation. I understand that my placenta has been handled and encapsulated according to OSHA and State Food Safety and Handling standards, and has been cleaned, cooked, dehydrated and put into pill form in a sanitary and sterile work space. Upon receiving my placenta capsules from my placenta specialist, I waive any and all rights to hold ZaMama responsible for any undesired effect of consuming the capsules. This may include an oversupply in milk, hormonal shift, anxiety or sleeplessness. These side effects are rare, but have been reported. I agree to stop taking the placenta capsules and contact ZaMama immediately if and when I experience any of these side effects.
I understand that upon receiving my placenta capsules, including but not limited to any other person(s) ingesting my own placenta capsules, ZaMama is no longer liable.
I do not hold ZaMama, my placenta specialist responsible or liable for any transport mishap that is beyond their control (ex. car accident or detainment), and understand that I am choosing to have the specialist encapsulate my placenta in the specialists home.
I do not hold ZaMama, my placenta specialist responsible or liable for my placenta while it is in the hospital.
I will contact ZaMama when labour begins so they are prepared for collection of placenta.
I will make sure that my placenta is refrigerated from or before 3 hours after birth.
After birth I will keep my placenta in sight at all times to ensure it does not go to a lab where it will be contaminated by chemicals or other harmful substances rendering it unsafe for consumption.
l will contact ZaMama within 12 hours (preferably sooner) of birth to notify of delivery or collection.
I understand that I need to complete final payment by 38 weeks pregnant and that the whole cost of Placenta encapsulation must be made before my placenta will be encapsulated.
I understand that my placenta capsules will take 24-72 hours to be ready for collection or delivery.
I understand that if my placenta cannot be encapsulated due to medical reasons I will be refunded all money paid with the exception of the non-refundable deposit of $100 plus a $50 on call fee.
I understand that if I decide to cancel my encapsulation before my 38 week gestation time, for any reason I will be refunded all money paid with the exception of the non-refundable deposit of $100.
I understand that if after 38 weeks I choose to not go ahead with placenta encapsulation simply because I change my mind I will not receive any refund.
If ZaMama is unable to provide placenta services due to illness or is otherwise incapacitated, all efforts will be made to send a back-up specialist. If ZaMama is unable to provide services and no back up specialist is available, the placenta can be frozen and encapsulated as soon as possible. If after this the service can still not be carried out, a full refund will be given.
Upon agreeing below and your payment/deposit, ZaMama will reserve your spot on the calendar. For this reason, the upfront payment includes a $100 non-refundable deposit.
I agree to all Terms and Conditions outlined above.
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