Placenta Encapsulation Agreement

Placenta Encapsulation Agreement

Maiyah C.| Placenta Encapsulation Specialist | Birth & Postpartum Doula
Placenta Encapsulation Disclaimer

Placenta encapsulation is the process of preparing the placenta after the birth of the baby by dehydrating, powdering and placing it into capsules for the person who gave birth to use at their discression.
Mother’s Name

First NameLast Name
Partners Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Estimated Due Date

DayMonthYear
Date
Planned birth location
Name of OB/GYN or midwife
Will this be your first birth ?
Are you allergic to latex?
Do you have any food or environmental allergies?*
If previous question is yes, please explain
Do you have any health complications? Are you taking any medication?
I understand and acknowledge that in accordance to Indiana law, 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 we or cultural. I also acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta in my home. I acknowledge that Fruit of Your Labor Doula Services has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta will be handled and encapsulated according to OSHA and Indiana Food Safety and Handling standards, and will be cleaned, steamed, dehydrated and put into pill form in a sanitary and disinfected work space. Upon receiving my placenta capsules from Fruit of Your Labor Doula Services, I waive any and all rights to hold them responsible for any undesired effect of consuming the capsules. If my placenta is not encapsulated in my own home, I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I understand that upon receiving the pills, Fruit of Your Labor Doula Services is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. I do not hold Fruit of Your Labor Doula Services responsible or liable for any transport mishap that is beyond their control
Client initials
understand that the turnaround time can vary between 3-5 business days.
Client initials
Client Responsibilty: It is your responsibility to compensate for services no later than two weeks before your estimated due date. If this amount is not received at this time, services cannot be guaranteed.It is your responsibility to notify me within THREE hours of the birth so that we can work together to make arrangements for pickup/drop off. Failure to do so may result in delayed placenta preparation and encapsulation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the placenta. Improper storage of the placenta prior to pick up or drop off may result in spoilage. It is your responsibility to discuss release of your placenta from the facility where you will give birth during the prenatal period and to ensure proper storage of your placenta in a refrigerator or cooler. This can be done by placing the placenta on ice until it can be retrieved for preparation and encapsulation. • It is also your responsibility to inform me of any known blood borne illness(es)or other health issues (such as HIV, hepatitis, etc.) that could place me or any others who may come in contact with your bodily fluids (specifically maternal and fetal blood as well as amniotic fluid) at risk. Some specific sexually transmitted diseases such as Hepatitis or herpes may preclude me from offering placenta encapsulation.
Client initials
I have read, understood, and agreed to the above information. I accept the responsibility of gaining possession of my Placenta and notifying my placenta specialist within 3 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below, I authorize the release of my healthy placenta to FOYL for the purposes of placenta encapsulation and keepsake preparation for my own personal use.
Client initials
FOYL Responsibilities: My responsibilities include maintaining client confidentiality, committing to preparing and returning your capsules within 72 hours of receiving your placenta (usually within 36-48 hours), and upholding the highest standards of cleanliness, safety, and quality of professional placenta preparation services.
Client initials
It is important to understand that there may be circumstances in which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending a sample of your placenta to pathology for further examination. Once the placenta has been released to pathology , I will not be able to encapsulate without an additional waiver.Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta could be harmful to your health. I will always consult with you prior to making a choice on whether or not your placenta is viable for ingestion. It should be possible to claim your placenta after caesarean surgery. It is important that you let me know if you have any health concerns or conditions which may affect the health of your placenta or the health and safety of anyone who may come into contact with your placenta.
Client initials
I understand that upon receiving my Placenta capsules/chocolates, my Placenta Specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules/chocolates.
Print name
Payment, Cancellation & Refund Policy- Payment in full is due before delivery of the capsules. - You may cancel this contract at any time but the $50 retainer is non-refundable and covers time spent prenatally and holding aside your space on our calendar. - If you cancel after I have picked up your placenta (or arrived for in-home preparation) but before preparation begins, I will return your placenta to you upon request and no further payment is required. - If you cancel after the encapsulation process has begun: the balance is due in full and no refund will be given even if you choose not to take delivery of the finished capsules.
Print name
Encapsulation Method

Traditional Chinese Method (TCM) • Placenta is gently steamed with warming herbs (lemon, ginger etc) dehydrated, ground into a fine powder, and placed into easy-to-take capsules.
I choose this type of capsule
A free digital photo of your placenta is included in your package. This is optional. Would you like a digital placenta photo
I grant Fruit of your labor (FOYL) and its representatives/subcontractors the right to use photographs/videos of my placenta.
Name & Number of partner or other person(s) who may contact us about your placenta:
Print name
My Products
prevnext( X )
🌱 Bloom Package
Keepsakes only Included: Placenta print (choice of two colors) & Umbilical cord encasing keepsake (Gold or Natural) • Pick up and drop off

$150.00



🌸 Nourish Package
Perfect option for families who only wish to encapsulate. *No keepsake art - just capsules * Choice of unflavored or strawberry flavored capsules Average capsule amount is between 90–150 capsules • Pickup and Drop off

$200.00 Quantity



⚜️The Legacy package
This package includes the creation of placenta capsules, a unique placenta art print, and an umbilical cord keepsake.*GOLD OR NATURAL* •Pickup and Drop off

$300.00 Quantity



Total

$0.00
I agree to the preceding Client Responsibilities, Limitations and Disclaimer and Refund Policy by signing below:
Should be Empty:

Placenta Encapsulation Agreement

Placenta Encapsulation Disclaimer

Encapsulation Method

My Products