Placenta Remedies Order Form

Your name

First NameLast Name

Birth partners name

First NameLast Name

Email address

example@example.com

Phone number

CountryPhone number

Your address

Street Address

Street Address Line 2

City or TownRegionPost CodeCountry

Estimated Due Date

Date

Where do you plan on birthing?

Do you have any allergies?

Have smoked past 12 weeks of pregnancy? Vaping is excluded.

Please tick if you have tested positive for any of the following:

Would you like to keep any parts of your placenta to bury?

How did you hear about my services?

Select products

T&Cs

Midwife Amy Placenta Bookings Terms & Conditions&#13;&#10;1. Any advice or information provided by Midwife Amy regarding Placenta Encapsulation is based on experience, research where available, documentation and client testimonials from mothers who have used placenta capsules and remedies for their post-partum recovery. However Midwife Amy does not guarantee benefits of Placenta Remedies.&#13;&#10;2. Midwife Amy is not a medical body and does not claim to treat, cure or relieve any symptoms in pregnancy, birth or post-birth.&#13;&#10;3. Client’s who choose to use the services of Midwife Amy take full responsibility for their own health and for researching and using the remedies we provide.&#13;&#10;4. The Client agrees to stop using the remedies immediately if feeling unwell and to seek advice.&#13;&#10;5. The Client agrees that Midwife Amy is not liable and do not take responsibility for any results or effects the Client may experience before, during or after consuming the placenta unless resulting directly from the negligence of Midwife Amy.&#13;&#10;6. The Client agrees that all placenta capsules and other placenta remedies, creams and balms are for the Client’s own use only and must not be shared with others.&#13;&#10;7. Midwife Amy will not make placenta encapsulation for Clients who have ever tested positive for HIV/AIDs, Hepatitis B and/or Hepatitis C, Active Genital Herpes, suffered from blood borne diseases.&#13;&#10;8. Midwife Amy does not take responsibility for damaged, lost or placentas that have not been adequately stored before the placenta comes into its care.&#13;&#10;9. The Client agrees to contact Midwife Amy in a timely manner, during labour and/or following birth, if this does not happen there may be a delay in collecting the placenta in the time stated when booking.&#13;&#10;10. The Client agrees to follow the instructions provided when storing their placenta.&#13;&#10;11. The Client agrees to ensure their placenta remains chilled and under 8°C until collection.&#13;&#10;12. The Client consents to the removal of the placenta from the hospital, birth centre, or home by Midwife Amy.&#13;&#10;13. Midwife Amy will attend home , birth centre or hospital within 48 hours for collection.&#13;&#10;14. When collecting from hospitals Midwife Amy specialists will meet the Clients designated person at an agreed meeting spot rather than enter the hospital.&#13;&#10;15. Placenta Tinctures take longer to process and will be posted out separately.&#13;&#10;16. Midwife Amy will use the home address found on the booking form for all correspondence and for delivery of remedies. It is the Clients responsibility to inform Midwife Amy of change of address.&#13;&#10;17. Placenta Smoothie can only be made in the Client’s home, using the Client’s own blender.&#13;&#10;Placenta must be brought to the Client’s home by the Client’s designated person.&#13;&#10;Smoothie will be transported back to the hospital (if applicable) by the Client’s designated person.&#13;&#10;18. Midwife Amy will not be liable for any remedies delayed, lost or damaged during transportation by NZ post.&#13;&#10;19. Deposit of $80 taken at the time of booking which is non-refundable.&#13;&#10;20. Full payment of any outstanding balance must be made prior to collection.&#13;&#10;21. Midwife Amy will not start processing the placenta until payment for the order is received in full.&#13;&#10;22. You, the Client, agree that all the information you have provided is correct and to the best of your knowledge. You also agree to inform Midwife Amy immediately of any changes to your Medical Information or address detailed on your booking form, before the encapsulation takes place.&#13;&#10;23. If one or several of the terms and conditions mentioned in this document are not applicable, all other terms and conditions still apply and the document is still valid.

Placenta Remedies Order Form

Select products*

Select products