INTAKE FORM

INTAKE FORM

INTAKE FORM
Expectant Mother's Full Name*

First NameLast Name
What is your preferred language?
Are you surrogate?

Yes, I amNo, I am not
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Estimated Due Date*
Your Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Planned Location of Birth*
Please include address of hospital, birth center or home birth location.
Babies Name
Babies Gender
How Many Babies Are You Pregnant With?*

SINGLETWINSTRIPLETS
Alternative Contacts Name*
Alternative Contacts Phone Number*
Relationship*
Alternative contacts relationship to you.
Which Placenta Service Would You Prefer?

Take it Easy Mama, where I pick up, prepare in my workspace & drop off.In Home Encapsulation, where I prepare in your own home.
Please Check Which Options You're Interested In

Placenta TincturePlacenta SalvePlacenta SmoothieLactation CookiesPlacenta Blood PrintPlacenta Colored Print
Would You Like an Optional Umbilical Cord Keepsake?*

Yes! Heart shapedYes! The word LOVEYes! Something elseNO! Encapsulate with my placenta
How did you hear about us?
Please list any medical conditions, allergies, pharmaceutical medications, supplements you may have/take or important information*
Are You Currently NEGATIVE for all STDs?*

YES, I am NEGATIVE for all STDsNO, I am POSITIVE for at least one STD(s)
You (expectant mother) will email, text or show Brittany Noelle your STD results or a doctors note stating that you are currently negative for STD(s) before your placenta is prepared.*

YES, I will provide proof of my STD statusNO, I will NOT show proof of my STD status
CONTRACT
I am not a licensed medical professional such as a care provider or physician and I am not able to diagnose, treat or prescribe for any health condition. Services and 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 ascribed benefits have not been evaluated or approved by the United States government or FDA. It is your responsibility to determine whether using placenta capsules can be beneficial to your wellbeing postpartum.*

YES, I agreeNO, I do not agree
It is 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 in my home.*

YES, I agreeNO, I do not agree
It is your responsibility to pay the $60.00 non-refundable deposit in a timely fashion in order to reserve your estimated due date to secure your spot for placenta encapsulation service. By not providing a timely deposit it may preclude me from scheduling you in as a client for placenta service. It is also your responsibility to provide payment for service/goods or remaining payment for service/goods right before placenta pick up or at the time of pick up. Your placenta will NOT be encapsulated unless payment is received.

YES, I agreeNO, I do not agree
My responsibilities include maintaining client confidentiality, committing to preparing and returning your capsules within 72 hours of receiving your placenta and upholding the highest standards of cleanliness, safety and quality of professional placenta preparation services.*

YES, I agreeNO, I do not agree
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 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 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 others who may come in contact with your placenta.*

YES, I agreeNO, I do not agree
In-home encapsulation (placenta being prepared in the home provided by expectant mother), it is your responsibility to be watchful & careful of the dehydrator once your placenta is dehydrating in your home. You must be sure that you or anyone living/visiting in your home does NOT touch, move or unplug machine without first contacting your placenta specialist. If for some reason your dehydrater is unplugged, turned off, moved etc. it may preclude me from finishing the encapsulation process for safety & health reasons and you will not be entitled to a refund. If for some reason there is an electrical power outage or dehydrator machine failure and your placenta is non-consumable you will then be entitled to half your cost refunded back. Refund received once investigation is final. Any travel fees are non-refunadable.*

YES, I agreeNO, I do not agree
If I have already taken possession of your placenta and you choose to not go forward with services, I will return your placenta to you and you will be given a refund (less) minus $200.00 (Any travel fees are non-refundable & $60.00 non refundable deposit is non refundable) for consultation, handling & travel. If for whatever reason you decide to forgo my services before I have taken possession of your placenta, you will be given a refund (less) minus $60.00 for consultation & travel. There will be NO REFUND once preparation has begun, even if you choose not to take delivery of the finished placenta capsules/goods.*

YES, I agreeNO, I do not agree
I have read, understood and agreed to the above information. By electronically signing below I authorize the release of my healthy placenta to Brittany Noelle; The Joyful Tree for purposes of placenta encapsulation services and keepsake preparation for my own personal use.*

YES, I agreeNO, I do not agree
Signature*
Date*

MonthDayYear
Date
LIABILITY
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 etc. I acknowledge that my placenta specialist has provided me with concrete information about both the benefits and risks of placenta encapsulation, and I have read all included documents. I understand that my placenta has been 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 clean and sanitary work space. Upon receiving my placenta capsules from my placenta specialist, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules/tincture/placenta food. This may include an oversupply in milk, hormonal shift, anxiety or sleeplessness; these side effects are rare, but have been reported. I agree to contact my placenta specialist immediately if and when I experience any of these side effects. I do not hold 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.

I understand & agreeI do NOT agree
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 put trust and faith that my placenta specialist has been trained and certified to correctly prepare placenta remedies. I have provided my placenta specialist with recent blood documentation stating that I have been tested for STD’s and the results were negative. Universal precautions for sanitizing are the same with each client, I understand and trust that my specialist retains blood work records for each client and that I am protected. I understand that upon receiving the pills, my placenta specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules.

I understand & agreeI do NOT agree
Signature
Date

MonthDayYear
Date
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