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 that placenta and in a sanitary environment.ZaMama business is adhering to strict OSHA guidelines and following proper food safety standards.
Name*

First NameLast Name
Estimated Due Date of Birth*

MonthDayYear
Date
Planned place of Birth*
Residential address for postage or delivery.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I choose to have my placenta encapsulated in the following way*

RAW ENCAPSULATION $300TCM (Traditional Chinese Method) Cooked ENCAPSULATION $3001/2 RAW AND 1/2 TCM $350I WILL LET YOU KNOW AT THE TIME OF ENCAPSULATION
I would like the following products to be made when my placenta is being encapsulated

Placenta Tincture 50ml (takes 6 weeks to make) $70Placenta Print on Paper with the blood of placenta $25Photos of my placenta( 4 digital pics ) $25None of the above
PLACENTA COLLECTION AND DELIVERY*

1. You can deliver your placenta to Edge Hill in Cairns and collect the capsules when they are ready.2. We can pick up your placenta from your place of birth within the Cairns City area, and you can collect from Edge Hill when they are ready. Cost $203. We can pick up your placenta from your place of birth within the Cairns City area, and then post/drop off (in Cairns City area) your capsules when they are ready. Cost $404. You can deliver your placenta to Edge Hill in Cairns, and we will post your capsules to you when they are ready. Cost $20I will let you know at time of encapsulation
Payment is to be made via Direct Bank Deposit. Would you like to pay

$100 deposit and the remainder before your 38 week time in pregnancyFull Payment (your total cost)Type option 3Type option 4
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.*

I AGREEType option 2Type option 3Type option 4
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)

HIVHEPATITIS CHEPATITIS BSYPHILIS
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.*

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Fees are for the service of encapsulating your placenta, not for the sale of the capsules.*

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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 AGREEType option 2Type option 3Type option 4
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.*

I AGREEType option 2Type option 3Type option 4
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 AGREEType option 2Type option 3Type option 4
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.*

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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 AGREEType option 2Type option 3Type option 4
I do not hold ZaMama, my placenta specialist responsible or liable for my placenta while it is in the hospital.*

I AGREEType option 2Type option 3Type option 4
I will contact ZaMama when labour begins so they are prepared for collection of placenta.*

I AGREEType option 2Type option 3Type option 4
I will make sure that my placenta is refrigerated from or before 3 hours after birth.*

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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.*

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l will contact ZaMama within 12 hours (preferably sooner) of birth to notify of delivery or collection.*

I AGREEType option 2Type option 3Type option 4
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 AGREEType option 2Type option 3Type option 4
I understand that my placenta capsules will take 24-72 hours to be ready for collection or delivery.*

I AGREEType option 2Type option 3Type option 4
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 AGREEType option 2Type option 3Type option 4
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.*

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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.*

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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.*

I AGREEType option 2Type option 3Type option 4
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 AGREEType option 2Type option 3Type option 4
I agree to all Terms and Conditions outlined above.*

I AGREEType option 2Type option 3Type option 4
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